Introduction

Introduction
Chronic Obstructive Pulmonary Disease (COPD) – a group of diseases that cause

airflow blockage and breathing related problems. It is a slowly progressive disease of the
airways that eventually leads to a gradual loss of lung function. Chronic persistent cough and
shortness of breath are the major symptoms of COPD.
Smoking is responsible for the majority of COPD cases, but there are several factors
that can put people at risk. It remains a major public health problem. It is the fourth leading
cause of chronic morbidity and mortality in the United States and is projected to rank fifth in
2020 in burden of disease cause worldwide according to a study published by the World
Health Organization (WHO). According to Department of Health (DOH), COPD is still the
third leading cause of morbidity and ranks eight to the top ten leading cause of mortality here
in the Philippines.
COPD develops slowly. Symptoms often worsen overtime and can limit the affected
individuals to do routine activities. Severe COPD may prevent them from doing even basic
activities like walking, cooking or even taking care of themselves. Most of the time, COPD is
diagnosed in the middle aged or older people. The disease is not passed from person to
person.
COPD has no definite cure yet. However treatment and lifestyle changes can make
the affected individuals feel better, stay more active, and slow the progress of disease.
Goal and Objectives

1
On the completion of this case study, the group will be able to have more
comprehensive understanding about chronic obstructive pulmonary disease (COPD), and
apply nursing care process appropriately.
Specifically, the group will be able to:
1. Correlate the patient's present and past medical and psychosocial history to the disease
process.
2. Do a physical assessment to a 51 year old male patient with COPD, and identify the
findings that correlate to the course of the disease.
3. Identify the major risk factors that contribute in the development of COPD based on the
patient's profile and history.
4. Describe the structures and functions of the respiratory system and illustrate the
pathophysiology of chronic obstructive pulmonary disease (COPD) and correlate the patient's
sign and symptoms, properly.
5. Identify the significant events that happened to the patient during the eight days course in
the ward.
6. Identify the nursing implications of various procedures used for diagnostic evaluation of
respiratory function and associate it with the patient's clinical manifestations, correctly.
7. Describe the indications, dosages, routes, precautions, and adverse effects of the
medications that the patient has been receiving, and emphasize nursing considerations on
giving these medications to Mr. P and his family, accurately.
8. Formulate a nursing care process as a framework for the care of the patient and implement
it accordingly.
9. Develop an exclusive discharge and home care plan, and provide health teaching to the
patient and patient's family about the disease, its major risks factors, signs and symptoms,
ways on how to reduce discomforts, and the importance of life-style modification,
rehabilitation, and follow-ups.
Patient's Profile
2
Name : Mr. P
Address : Sta. Cruz, City of Manila
Sex : Male
Birth Date : August 11, 1957
Age : 51 Years Old
Height : 5 feet and 9 inches/172 centimeters
Weight : 365 pounds/165 kilograms
Occupation : Policeman
Civil Status : Married
Birth Place : City of Manila
Nationality : Filipino
Religion : Roman Catholic
Date of Admission : June 18, 2009
Date of Discharge : July 08, 2009
Admitting Diagnosis : Chronic Obstructive Pulmonary Disease in Acute Exacerbation
History
Chief Complaint: Difficulty of Breathing
3
History of Present Illness
One week before admission, Mr. P sought consultation at the United Doctors Medical
Center in Manila because of difficulty of breathing, intermittent fever and chronic cough with
thick yellowish secretions. He was not admitted but was prescribed of maintenance
medications which were cefuroxime 500 mg capsule daily and azithromycin 500 mg capsule
daily for 3 days both taken orally.
A day before admission, Mr. P again experienced difficulty of breathing with easy
fatigability at rest and chest heaviness upon exertion and his productive cough was persistent.
He was then rushed to the Philippine Heart Center and sought medical attention immediately.
On assessment, Mr. P was awake, coherent, oriented to time, place and person. Vital
signs were taken: blood pressure of 240/120 mmHg, taken on the left arm in sitting position;
cardiac rate of 99 beats per minute; respiratory rate of 28 cycles per minute with the use of
accessory muscles; temperature of 36.7 degree celsius taken in the right axilla. Mr. P
exhibited no motor deficits. With pink palpebral conjunctivae, anicteric sclera, and no neck
vein engorgement. On auscultation, wheezes and crackles were heard on lung fields, apical
beats not appreciated, no heart murmurs heard. Abdomen looked flabby, soft and tender.
Cyanosis was not evident. Grade 2 edema noted on both feet. Peripheral pulses were full and
equal. Mr. P reported that he has a regular bowel movement and urinary pattern. He also
reported that he cannot sleep when lying flat on bed that he needs to get up or sleeps in a
sitting position. Initial x-ray revealed show progression of pulmonary congestion to edema.
He was then managed primarily as a Chronic Obstructive Pulmonary Disease (COPD) in
acute exacerbation.
Initial medications given to Mr. P were: Salmeterol Xinafoate1 via inhalation twice a
day, Pulmicort Turbuhalen 1 tablet every 12 hours, Ertepenem Sodium 1 gram per
Intravenous once a day, Azithromycin 500 milligram 1 tablet two times a day and
Cefuroxime sodium 750 milligram every 6 hours, and Methylprednisone 16 milligram 1
tablet once a day.
Past Medical History
Mr. P was diagnosed with asthma when he was in grade school. He verbalized that
cigarette smoke and air pollutants such as dust triggered his asthma but occurred very rarely.
And five years ago, he was diagnosed with diabetes mellitus type II. According to him, his
father was also asthmatic, and further added that his mother was diagnosed with diabetes
mellitus.
According to Mr. P, he started cigarette smoking at the age of twelve and when he
turned fifteen, he can consumed four packs of cigarettes daily and also began to drink
alcoholic beverages.
History
4
In 2006, Mr. P first experienced difficulty of breathing with the development of
chronic cough with clear sputum, and easy fatigability on moderate exertion. This prompted
him to seek medical attention at the United Doctors Medical Center (UDMC) in the City of
Manila and was diagnosed with chronic obstructive pulmonary disease and immediately
received medical treatments. In the same year, Mr. P once again admitted at the same
hospital as a result of exacerbation of the disease, same happened in 2008.
In January 2009, Mr. P was admitted again at the UDMC because of worsening
symptoms of COPD such as increased production of respiratory secretions, frequent
difficulty of breathing on mild exertion and pulmonary crackles. After five days, Mr. P and
his family requested to get discharged, however the hospital rejected the request and referred
them to the Philippine National Police General Hospital (PNPGH). But because of hospital
lack of facilities, Mr. P was then referred to the Philippine Heart Center.
On January 28, 2009, Mr. P was first admitted at the Philippine Heart Center due to
COPD in acute exacerbation with the additional findings of community acquired pneumonia,
hypertension, cor Pulmonale, coronary artery disease and nephropathy secondary to diabetes
mellitus. On February 09, 2009, twelve days after admission, Mr. P was discharged with
maintenance medications and advised to have check ups at least two times in a month.
Personal, Environmental and Psychosocial History
Mr. P was a graduate of criminology and is presently working as a policeman with the
rank of Senior Police Officer 2 at the Manila Police Department since 1980. His specific duty
is to respond when there is an emergency operation. He was married to Mrs. P in 1979. Mrs.
P manages a small convenient store near their house. Mr. and Mrs. P have one son and four
daughters, but three of them have their own families and live in their own residences.
During the initial interview, Mr. P proudly said, "…brusko ako, lalake ako, lalo na sa
linya ng trabaho ko kaya madalas ako manigarilyo", and further added, "…halos lahat ng
kasama ko ay naninigarilyo". His daughter also said that his brother is also a cigarette smoker
and usually smokes inside their house. In addition, Mr. P reported that in a day, he drinks
eight to ten cups of coffee.
According to Mrs. P, his husband frequently attended group gatherings before with
his workmates and went home drunk and smelled like a cigarette smoke. Mrs. P added that
although his husband was diagnosed with COPD in 2006, he still consumed eight to ten
sticks of cigarettes a day. Together with her daughter, they encouraged Mr. P to stop but it
was all futile. Mr. P’s daughter added that his father does not strictly comply with his
maintenance medications.
Physical Assessment
5
Initial Assessment : June 30, 2009, 04:15 PM
Final Assessment : July 07, 2009, 03:30 PM
GENERAL SURVEY
INITIAL FINAL
Mr. P was lying on his bed on a semi- Mr. P was sitting on the right side of his
fowler's position; considerable in size; 160 bed; ambulatory; 158 kilograms; wearing
kilograms, 5 feet and 9nches in height; white t-shirt and generally appeared clean;
without upper body clothing and generally fully conscious and aware of surroundings;
appeared clean; fully conscious and aware voice was less hoarse; effectively
of surroundings; hoarse voice; effectively expectorates thick moderate yellowish
and frequently expectorating thick secretions; no intravenous fluid noted; No
moderate yellowish secretions; with an cardiac monitor, pulse oximeter and oxygen
ongoing intravenous fluid of Plain Normal attached; Mr. P was accompanied by his
Saline Solution (PNSS) at 500 milliliters wife and two daughters. Ready for
level, running at 60 milliliters per hour plus discharge on the next day.
antibiotic, patent and infusing well at the
left metacarpal vein; attached to oxygen per
nasal cannula at 6 liters per minute, cardiac
monitor with the cardiac rate of 77 beats
per minute and pulse oximeter with 95%
oxygen saturation; Mr. P was accompanied
by his wife and daughter.
CENTRAL NERVOUS SYSTEM
INITIAL FINAL
Fully conscious and aware of surroundings; Alert and oriented to time, place and
communicates verbally and actively; with a person; with a GCS of 15; sensory
Glasgow Coma Scale (GCS) of 15 functions intact, no numbness, tingling or
(spontaneous eye opening, 4; oriented and burning sensation reported; motor
Physical Assessment
6
CENTRAL NERVOUS SYSTEM
INITIAL FINAL
Cont. converses clearly, 5; and obeys functions were intact; no seizure episodes
command,6); sensory functions intact, no since June 23, 2009; can maintain balance
numbness, tingling or burning sensation and stance for more than 5 seconds when
reported; motor functions were intact; with asked to stand.
a history of generalized seizure last June
22, 2009
CARDIOVASCULAR SYSTEM
INITIAL FINAL
Mr. P was attached to cardiac monitor Cardiac monitor and pulse oximeter were
and pulse Oximeter: ECG tracing showed no longer attached to Mr. P; Radial pulse
normal sinus rhythm, cardiac rate of 77 was 73 beats per minute; blood pressure of
beats per minute, oxygen saturation of 95% 130/90 mmHg; no lifts and pulsations noted
; blood pressure of 130/80 mmHg taken on on the precordium; no neck vein distension
the left arm, with pulse pressure of 50; and heart murmurs noted; capillary refill of
Upon palpation of the precordium, lifts 2-3 seconds; full and bounding peripheral
and pulsation was not noted; jugular vein pulses; bipedal edema no longer present.
was not visible; on auscultation, no heart
murmurs heard; no evidence of bleeding;
mucus membrane appeared pinkish; with a
capillary refill of 2-3 seconds; pinkish nail
beds, no clubbing noted; full and bounding
peripheral pulses; limbs not tender and
symmetrical in size; skin of the hands was
not warm or cold to touch, not edematous;
with grade 1 bipedal edema.
Physical Assessment
7
RESPIRATORY SYSTEM
INITIAL FINAL
Head of the bed elevated to 35-45 degree No evidence of difficulty of breathing; with
angle; with evidence of difficulty of shallow respiration; respiratory rate was 25
breathing; with a respiratory rate of 26 cycles per minute; symmetrical chest
cycles per minute; No mechanical expansion; use of accessory muscle was
ventilator and endotracheal tube in place; evident; normal ratio of anteroposterior
symmetrical chest expansion; use of diameter to transverse diameter; fine and
accessory muscles was evident; no barrel short interrupted crackling sounds and
chest noted (normal anteroposterior to wheezing were still heard on auscultation
transverse diameter in ratio of 1:2); of both lungs; lips formed as if Mr. P is
presence of fine, short interrupted smoking a pipe more evident when
crackling sounds and wheezing heard on speaking and when asked to ambulate;
auscultation of both lungs; lips formed as if decreased tactile fremitus; can effectively
Mr. P is smoking a pipe especially when expectorates thick moderate yellowish
speaking; spine were vertically aligned; secretions.
chest wall intact, no tenderness noted;
decreased tactile fremitus on palpation;
can effectively expectorate thick moderate
yellowish secretions.
GASTROINTESTINAL SYSTEM
INITIAL FINAL
Upon inspection, abdomen was uniform in Rounded abdomen; liver or spleen

color, rounded; no evidence of enlargement enlargement was not noted; bowel sounds
of the liver or spleen; symmetric contour; audible; no arterial bruits; tympany over
Physical Assessment
GASTROINTESTINAL SYSTEM
8
INITIAL FINAL
Cont. peristalsis was not clearly visible; on stomach and dullness over the liver; no
auscultation, bowel sounds were audible, tenderness reported.
no arterial bruits heard; tympany over the
stomach and gas-filled bowels, and
dullness over the liver upon percussion; on
palpation, mild tenderness reported by Mr.
P.
URINARY SYSTEM
INITIAL FINAL
With foley catheter in place draining amber No urinary catheter noted; Mr. P reported
colored urine; urine output was 90 that he had no difficulty in urinating; he
milliliters for the last two hours; no reported that he urinated thrice in the last
hematuria noted; bladder not distended; two hours; bladder not distended.
Mr. P reported that he was on bladder
training.
INTEGUMENTARY SYSTEM
INITIAL FINAL
Uniform deep brown skin color except in No pressure sores, wounds, abrasions or
areas exposed to the sun; no pressure sores, other lesions noted pressure sores noted;
wounds, abrasions or other lesions noted; bruises were no longer visible on the radial
mild bruises on lower right arm and radial area; with good elasticity.
area; skin sprang backed to previous state
when pinched.
Physical Assessment
MUSCULOSKELETAL SYSYTEM
9
INITIAL FINAL
Equal size on both sides of the body; no Equal size on both sides of the body; no
weakness or paralysis; no contracture in weakness or paralysis; no contracture in
muscles and tendons; tremors was not muscles and tendons; tremors was not
evident; muscles were firm at rest with evident; muscles were firm at rest with
equal strength on each body side; no equal strength on each body side; no
deformities, tenderness noted; full range of deformities, tenderness noted; full range of
motion; no joint pain or stiffness; was able motion; no joint pain or stiffness; was able
to turn from side to side. to turn from side to side.
PSYCHOSOCIAL SYSTEM
INITIAL FINAL
Mr. P expressed that it was hard for him to Mr. P said that he was excited to go out
be hospitalized and experienced difficulties from the hospital and fully motivated to
duet to his disease. However, he was comply on his medical regimen. Two
hopeful that he can recover very soon as he daughters and Mrs. P expressed support to
modifies and strengthens his life-style and Mr. P.
by complying with his medical regime; Mr.
P's support system was adequate with his
wife, daughters, and son frequently
accompanying and visiting him.
Anatomy and Physiology
10
Philippi
ne Heart Center
Like the heart, surrounded by the pericardium, the lungs are likewise enclosed in a
two piece membrane called the pleura lining. This is a thin membrane which lines the inside
of the chest cavity and also covers the lungs. The two "pleural cavities" (one for each lung)
are enclosed compartments, with normally only a film of lubricating fluid between the layer
lining the chest (parietal pleura) and the layer covering the lungs (visceral pleura).
The "visceral" layer covering the lungs is continuous with the "parietal" layer that
covers the inner surface of the chest cavity -- like a balloon folded over on itself. The thin
layer of fluid, which separates these two layers amounts to less than 10 ml (about 1/3 of an
oz) total in the normal adult lungs. This fluid contains both mesothelial cells and a significant
concentration of mucopolysaccharides, which acts as a lubricant for the smooth movement of
the pleural layers against one another. The two layers continually tend to pull away from
each other, because of the stretched elastic condition of the lungs -- an important factor in the
mechanics of breathing. If the chest wall is penetrated by a wound, air is readily sucked into
the pleural cavity, separating the two pleural layers and collapsing the lung.

Air is conducted from the nose and mouth down into the lungs by the trachea (a tube
made primarily of cartilage that serves only one purpose -- to conduct air). At the bottom of
the trachea, the passageway splits into two bronchial tubes called the mainstem bronchi --
one heading into each lung. The mainstem bronchi then divide progressively into smaller and
11
smaller segmented bronchi as they spread into the lungs. The bronchi are, like the trachea,
are primarily composed of inflexible cartilage. Again, they are used for conduction of air
only. At the lowest or smallest level, however, the bronchi change. The cartilage is mostly
gone, and the composition is now mostly flexible muscle. These terminal bronchi are called
bronchioles. As we saw with the cardiovascular system, the muscle tissue at this level allows
the bronchioles to expand and contract -- thus directing air flow to the different parts of the
lung as needed. The whole system is known as the tracheal-bronchi tree -- and it in fact
looks like a tree if you turn it upside down, with the trachea serving as the trunk of the tree.
After the division of the mainstem bronchi, each lung divides itself into three lobes --
although in the left lung, the upper and middle lobes have merged together, making it look
like there are only two lobes. The lobes are then divided into smaller segments named after
the bronchi that go into them. From a surgical point of view, it is far easier to remove an
entire lung, as opposed to just a piece of lung since you only have to staple off the one large
bronchi and one main blood vessel. Lobes are also fairly easy to remove in that you are still
dealing with just a handful of bronchi and blood vessels. But if you try and remove a piece of
a lobe, you must close off dozens of bronchioles and blood vessels.
Exchange system
At the end of all the bronchioles are the

alveoli, the microscopic air sacs that serve as the
exchange system of the lungs. It is the alveoli that
interact with the vast network of tiny pulmonary
arterioles, venules, and capillaries -- exchanging
oxygen for carbon dioxide and refreshing the blood.
The network of arterioles and venules literally cover
the alveolar sacs complete with a spider web like
network, providing access to every square inch of
lung tissue. The actual exchange of gases takes place
at the level of the pulmonary alveolar capillaries --
the tiniest part of the system.

Alveoli begin to appear in the walls of the 17th generation of bronchioles. By the 20th
generation of bronchioles, the entire wall of the airway is composed of alveoli. But the actual
alveolar sacs, the bottom line of the lung so to speak, make their appearance at the 23rd
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Philippi
ne Heart Center
generation of alveoli. There are approximately 300 million alveoli within the lungs,
providing a surface area about the size of a tennis court. The barrier separating the pulmonary
capillaries from the air in the alveolar sacs is composed of a layer of endothelial cells, a small
interstitial space, and a layer of pulmonary epithelial cells known as pneumocytes. The
exchange of oxygen for carbon dioxide in blood cells takes place across this barrier.
The tissue separating the endothelial cells and the epithelium of the lungs contains
elastic, collagen fibers that give structural integrity and elasticity to the pulmonary tissues.
When the chest cavity is opened, it is the elasticity of the lungs that acts to expel all of the air
remaining in the lungs, which then collapse. This becomes significant when we talk about
emphysema. One of the effects of emphysema is that it destroys those elastic fibers, which
severely impacts the ability of the lungs to adequately contract, significantly impacting the
ability of the patient to breathe. At the other end of the spectrum, however, an overgrowth of
fibrous elastic tissues in the lungs happens in patients with pulmonary fibrosis and is
responsible for the difficulty that they experience during inhalation -- both in terms of the
ability of the lungs to expand and contract and the ability of carbon dioxide and oxygen to
freely pass between the pulmonary capillaries and the alveoli.
Another issue to consider is that for this system of gas exchange to work, the alveolar
sacs must be composed of many, many separate alveoli so that the sac itself looks something
like a bunch of grapes. The reason the multitude of alveoli is necessary is that they provide a
vast surface area to accommodate the multitude of pulmonary capillaries required to "feed"
the system and exchange sufficient gases. (As we mentioned a couple of paragraphs ago, in a
pair of healthy lungs, the surface area is equivalent to that of a tennis court.) In some
diseases, such as emphysema, the walls of the individual alveoli break down leaving you
with one sack as opposed to "the bunch of grapes." The net effect is a dramatically reduced
surface area of the lungs, thereby limiting the ability of the lungs to exchange gases -- thus
the resulting shortness of breath.
It is important to note that the lungs (and for the most part we're talking about the
alveoli) are not actually hollow, but rather, sponge like. If you cut a section of the lung, it
does not look like a balloon, but like a sponge. And in fact, if you squeeze the tissue, tiny
little bubbles come out -- just like squeezing a sponge.
It should also be noted that the alveoli are extremely susceptible to complications if
any foreign particles or fluids enter them since they have no good mechanism for their
removal. Pneumonia is often the end result. In fact, the defense mechanisms to prevent this

are in the trachea and large bronchi, which, as we discussed earlier, are lined with cells that
have a vast area of hair like projections called cilia that beat upwards in an attempt to move
13
the particulate matter (including cigarette smoke, air pollution, or coal dust) out into the
throat, where it can be cleared by coughing or clearing the throat. It's probably worth
mentioning that one of the first effects of smoking cigarettes or inhaling heavily polluted air
is that you destroy these cilia -- and thus the ability of your lungs to protect themselves from
further smoking or exposure to particulate matter. Once started, it's a vicious circle.
Diaphragm and Chest wall
The last part of the respiratory system

we'll talk about is the diaphragm, which is a
large, sheet-like muscle. It separates the
thoracic cavity, which holds the lungs and
heart, and the abdominal cavity, which holds
the stomach, intestines, kidneys, and liver.
Like the cavities it separates, it too is
comprised of two distinct portions. The costal
portion is attached to the ribs and is
responsible for ventilation. The ribs
meanwhile, which define the chest wall, are
connected by two layers of intercostal
muscles. The outer layers run diagonally
downward and forward from the upper to
lower ribs and act to lift the chest cavity. The
internal intercostals run diagonally in the opposite direction and assist in exhalation. The
scalene muscles run from the first five vertebrae to the first two ribs and lift the chest cage
during inhalation.
The diaphragm is crucial for breathing and respiration. During inhalation, the
diaphragm contracts, thus enlarging the thoracic cavity (the external intercostal muscles also
participate in this enlargement). This reduces intra-thoracic pressure. In other words, by
enlarging the chest cavity, you create suction that draws air into the lungs. When the
diaphragm relaxes, air is exhaled by the elastic recoil of the lungs and the tissues lining the
thoracic cavity in conjunction with the abdominal muscles, which now push inward and help
the diaphragm rise up and shrink the size of the chest cavity forcing air out.
Pathophysiology
In Chronic Obstructive Pulmonary Disease
(COPD), the airflow limitation is both progressive
14
and associated with an abnormal inflammatory response of the lungs to noxious particles or
gases. The inflammatory response occurs throughout the airways, parenchyma, and
pulmonary vasculature.
Chronic Bronchitis, a disease of the airways, is

defined as the presence of cough and sputum
production for at least three months in each of two
consecutive years. In many cases, smoke or other
environmental pollutants irritate the airways,
resulting in hypersecretion of mucus and
inflammation. This constant irritation causes the
mucus-secreting glands and goblet cells to increase
in number, ciliary function is reduced, and more
mucus is produced. The bronchial walls become
thickened, the bronchial lumen is narrowed, and
mucus may plug the airway. Alveolar adjacent to the
bronchioles may become damaged and fibrosed,
resulting in an altered
function of the alveolar macrophages. This is significant because the macrophages play
important role in destroying foreign particles including bacteria. As a result, the patient
becomes more susceptible to respiratory infection. A wide range of viral, bacterial, and
mycoplasmal infections can produce acute episodes of bronchitis. Exacerbations of chronic
bronchitis are most likely to occur during the winter.
In Emphysema, impaired gas exchanged (oxygen, carbon dioxide) results from

destruction of the walls of overdistended alveoli. "Emphysema" is a pathological term that
describes an abnormal distension of air spaces beyond the terminal bronchioles, with
destruction of the walls of the alveoli. It is the end stage of process that has progressed
slowly for many years. As the walls of the alveoli are destroyed (a process accelerated by
recurrent infections), the alveolar surface area in direct contact with the pulmonary
capillaries continually decreases, causing an increase in dead space (lung area where no gas
exchange can occur) and impaired oxygen
diffusion, which leads to hyoxemia. In the later
Pathophysiology
15
stage of the disease, carbon dioxide elimination is impaired resulting in arterial blood
(hypercapnia) and causing respiratory acidosis. As the alveolar walls continue to breakdown,
the pulmonary capillary bed is reduced. Consequently, pulmonary blood flow is increased,
forcing the right ventricle to maintain higher blood pressure. Thus, right-sided heart failure
(cor pulmonale) is one of the complications of emphysema.
Risk factors for COPD include environmental exposures and host factors. The most
important risk factor for COPD is cigarette smoking. Pipe, cigar, and other types of tobacco
smoking are also risk factors. In addition, passive smoking contributes to respiratory
symptoms and COPD. Smoking depresses the activity of scavenger cells and affects the
respiratory tract's ciliary cleansing mechanism, which keeps breathing passages free of
inhaled irritants, bacteria, and other foreign matter. When smoking damages this cleansing
mechanism, airflow is obstructed and air becomes trapped behind the obstruction. The alveoli
greatly distend, diminishing lung capacity. Smoking also irritates the goblet cells and mucus
glands, causing an increased accumulation of mucus, which in turn produces more irritation,
infection, and damage to the lung. In addition, carbon monoxide (a byproduct of smoking)
combines wit hemoglobin to form carboxyhemoglobin. Hemoglobin that is bound by
carboxyhemoglobin cannot carry oxygen efficiently.
Smoking is not the only risk factor for COPD. Other factors include prolonged and
intense exposure to occupational dusts and chemicals, indoor air pollution, ad outdoor air
pollution, which adds to the total burden of inhaled particles on the lung.
A host risk factor for COPD is a deficiency of alpha1 anti-trypsin, an enzyme
inhibitor that protects the lung parenchyma from injury.
COPD is characterized by three primary symptoms: cough, sputum production, and
dyspnea on exertion. These symptoms often worsen overtime. Chronic cough and sputum
production often precede the development of airflow limitation by many years. However, not
all individuals with cough and sputum production will develop COPD. Dyspnea may be
severe and often interferes with the patient's activities. Weight loss is common because
Pathophysiology
dyspnea interferes with eating, and the work of breathing is energy depleting. Often the
patient cannot participate in even mild exercise because of dyspnea; as COPD progresses,
dyspnea occurs even at rest. As the work of breathing increases overtime , the accessory
muscles are recruited in an effort to breath. The patient with COPD is at risk for respiratory
insufficiency and respiratory infections, which in turn increase the risk for acute and chronic
respiratory failure.
16
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ne Heart Center
In COPD patients with a primary emphysematous
component, chronic hyperinflation leads to "barrel
chest" thorax configuration. This results from fixation
of the ribs in the inspiratory position (due to
hyperinflation) and from loss of lung elasticity.
Retraction of the supraclavicular fossae occurs on
inspiration, causing the shoulder to heave upward. In
advance emphysema, the abdominal muscles also
contract on inspiration.
17
Pathophysiology
Constant irritation Mucus secreting gland and goblet cells increased; infiltration of
MR. P'S RISK FACTORS inflammatory cells and release cytokines
Almost 40 years of cigarette (neutrophils, macrophages, lymphocytes, leukotrines, interleukins
smoking
Passive smoking
Prolonged and intense
exposure to ambient air Bronchial lumen narrowed; mucus plug the airway; alveolar Reduced bronchial ciliary
pollution (noxious particle) adjacent to bronchioles becomes damaged and fibrosed function; more mucus produced
Asthma
Altered function of alveolar macrophage

Recurrent respiratory tract infection Increased protease activity with
breakdown elastin in connective tissue
Irreversible enlargement of air spaces distal to terminal of lungs
Destruction of alveolar walls and loss of elastic recoil of bronchial walls
Loss of fibrous and muscle tissue breakdown of alveolar elasticity A portion of the capillary bed of an alveolus has been
macropge eliminated
18
Loss of fibrous and muscle tissue
breakdown of alveolar elasticity
macrophage Alveoli cannot support Inability of the alveoli to
the airways to keep recoil normally after
them open expanding
(decreased tactile fremitus on
Change in airway size
palpation)
Amount of air that can
be expired is
Lungs become less compliant Dyspnea on exertion diminished
Bronchiolar collapse
on expiration
Airway trapping (crackles and wheezes)
Chest X-ray
Inability of the lungs to circulate
sufficient air
Overdistended Increased pulmonary vascular
lungs resistance
Pulmonary
function Test
Increased total Pulmonary hypertension

Part of each inspiration is trapped lung capacity and
residual volume
Arterial Blood Gas
Cor Pulmonale
hypoventilat Decrease
ionn oxygenatio echocardiography
tachypnea
n Chest X-ray
LEGEND
Gray box – usual pathway Broken Line Box – Laboratory and Diagnostic
Test
Black Box - complication 19
Course in the Ward
DATE KEY TASK / FOCUS OF
ACTIVITIES RESPONSIBILITIES
June 30, 2009 Progress weaning as Determine the client’s

Thursday follows: readiness.
6 LTP x 1.5 hrs Assess how well Mr. P is

MV x 30 min healing from the COPD. If
6 LTP x 2 hrs he’s stable on antibiotics. Has
MV x 30 min a normal temp. Has a vital
within normal limits and he’s
able to cough up secretions.
In addition, assess
hemoglobin level, which
should be at least 8 gm/dL.
Also be sure magnesium,
potassium, and phosphorus
are within normal range,
since low levels of
electrolytes impair respiratory
muscle function.
Explain the weaning plan.

Assure him that you'll coach
him throughout the weaning
process. Explain that he may
experience some discomfort
when he starts breathing
without the assistance of the
ventilator, as he would if he
were exercising other muscles
that he hadn't used in a while.
Explain that you'll
continually monitor his vital
20
Course in the Ward
Cont. Progress weaning as signs and the amount of air

June 30, 2009 follows: he's breathing. Reassure him
Thursday that you'll stop the trial if he
6 LTP x 1.5 hrs feels anxious about
MV x 30 min continuing, he has trouble
6 LTP x 2 hrs breathing, or his blood
MV x 30 min pressure, respiratory rate,
pulse, or ECG indicates
fatigue.
To help him relax and better

tolerate the trial, encourage
him to listen to music, watch
television, or hold the hand of
a loved one.
Using the T-piece technique,

the nurse or the RT
disconnects the ventilator and
the patient spontaneously
breathes humidified oxygen
through the T-piece for
increasing periods of time.
(1.5 hrs to 2 hrs as ordered).
Monitor for distress during

weaning
pay particular attention to
oxygenation status. His
mental status should not
change.
21
Course in the Ward
Cont. Progress weaning as Your client's oxygen

June 30, 2009 follows: saturation should remain
Thursday above 85% – 90%, PaO2
6 LTP x 1.5 hrs should be greater than 60 mm
MV x 30 min Hg, and pH should be in the
6 LTP x 2 hrs range of 7.25 – 7.40,
MV x 30 min according to baseline values.
Also, he should remain

hemodynamically stable, with
his heart rate less than 140
and systolic BP be tween 90
and 180 mm Hg. Heart rate
and BP should not vary by
more than 20% from his
baseline values. Respiratory
rate should be less than 35
and not change by more than
50% from baseline.
Watch for perspiration and

muscle strain in the neck and
chest, signs that your client is
not tolerating the trial.
Paradoxical breathing
patterns, including abnormal
movement of the thoraco
abdominal muscles, inward
movement of the abdomen
during inspiration, and a
different rate of motion
between the chest and
abdomen, also indicate
distress
22
Course in the Ward
June 30, 2009 Start Bladder training Before beginning the

Thursday procedure, explain to the
client the reason for bladder
training, how long it will be
in place, and explain that
he/she should not experience
pain with the procedure, only
a pressure sensation and an
initial urge to void, both of
which will disappear. Be sure
to provide privacy for the
procedure.
The catheter may be clamped

for short periods of time and
then released. (4 hours
clamped and 30 minutes
unclamped) This causes some
bladder distention and
stimulation of bladder
musculature.
The nurse should expect, as

an outcome, that the patient is
able to void adequate
amounts at normal intervals
and that the client’s urine is
clear.
23
Course in the Ward
June 30, 2009 Extubation Obtain necessary oxygen

Thursday Prepare NIV delivery device ordered by
physician for post-extubation
9:00 am usage and assemble.
Explain procedure to client.

Note heart rate, blood
pressure, and respiratory rate.
Physician orders are followed
for extubation procedure.
Apply appropriate personal

protective equipment after
washing hands. Roll head of
bed up if possible.
Oxygenate client with 100%

oxygen and suction artificial
airway of secretions.
Hyperinflation should also be
incorporated for more
adequate removal of
secretions. Suction
oropharyngeal and/or
nasotracheal secretions.
Attach syringe to pilot
balloon cuff, if present.
Remove securement devices
from the artificial airway.
24
Course in the Ward
Cont. Extubation If possible, instruct the

June 30, 2009 Prepare NIV patient to take a deep breath
Thursday in and deflate the cuff, and
quickly remove artificial
9:00 am airway. If possible, instruct
patient to cough. Assist
Patient with secretion
removal Place oxygen
delivery device, as ordered by
physician, on client. Obtain
arterial blood gas, other lab
work or monitor pulse
oximetry. Discard personal
protective equipment and
wash hands.
Assess client's ability to

remove secretions.
If patient needs cough and
deep breathing instruction,
instruct and assist client with
maneuvers as ordered by
physician.
If client has rhonchi, crackles,
wheezes, or stridor,
appropriate respiratory
therapeutic interventions,
bronchodilators or racemic
epinephrine or chest
physiotherapy or
combination.
25
Course in the Ward
Cont. Extubation Document Toleration of

June 30, 2009 Prepare NIV extubation procedure,
Thursday physician in attendance, lab
work,
9:00 am pulse oximetry, oxygen
delivery device, therapeutic
interventions (if applicable).
Verify written physician
order for extubation, lab
work, oxygen delivery
device, or any additional
therapeutic measures, if
applicable.

June 30, 2009 Start Non invasive Explain the purpose of NIV
Thursday ventilator
Skin protection is an
important nursing
consideration and the use of a
hydrocolloid dressing to
prevent damage to the bridge
of the nose and forehead is
advocated clients have also
been known to develop
pressure damage around their
ears if the headgear is too
tight.
Course in the Ward

26
Cont. Start Non invasive Regular observation of the

June 30, 2009 ventilator eye area is necessary. The
Thursday ventilator compensates for
small leaks, which are
permissible provided they are
not near the patient's eyes as
this can lead to dryness and
the development of
conjunctivitis
Using a facial mask increases

the risk of aspiration if the
patient vomits. Therefore
medicines that may cause
nausea should be avoided and
the use of anti-emetics should
be considered. As gastric
distension is a possible side-
effect, the abdomen should be
assessed at regular intervals
and a nasogastric tube should
be used intermittently to
release the air.
Once a client's clinical

condition begins to stabilize
the mask may be removed for
short periods to allow for
eating and drinking. It is
important to maintain
adequate hydration, which
will also improve sputum
expectoration.
Course in the Ward

27
July 1, 2009 Mr. P for Chest x-ray Explain the procedure to

client
No advance preparation is
necessary.
take off jewelry that might be
in the way of the X-ray
picture. take off all or most of
the clothes above the waist
Explain the need to hold very

still during the X-ray to
prevent blurring of the
picture. Asked the client to
hold their breath for a few
seconds while the X-ray
picture is taken.

July 2, 2009 Diet: mechanically soft diet Explain the general principles
with limited source of of the diet to the patient, and
simple sugar at 1200kcal obtain the patient's
<2g Na, <200mg cholesterol cooperation. Teach the client
about the relationship
between his insulin and the
amount of food consumed.
Observe the client's reaction
to the diet. If the patient
understands the relationship
between his condition and his
diet
Course in the Ward

28
July 3, 2009 Mr. P for 2d-echo Facilitate diagnostic exam

The client may eat and drink
as normally would on the day
of the echocardiogram test.
Continue facilitating giving
of medications at the usual
times, as prescribed by the
doctor
Explain the procedure in

detail, including possible
complications and side
effects. Be available to
answer any questions the
client may have. Give a gown
to wear for your client upon
echocardiography procedure.
Instruct the client that he will
be asked to remove his
clothing from the waist up.
Also, client may be asked to

hold their breath at times.
And reinforce that they
should feel no major
discomfort during the test.
Course in the Ward
29
July 4, 2009 Hyperkalemia Educate client & family on

Saturday K=5.2 functions of potassium and
the effects if it is in excess.
Instruct to avoid potassium

rich foods.
Do not administer potassium-

containing intravenous fluids.
>Monitor for side effects of
hyperkalemia.
Monitor serum potassium

level.

July 5, 2009 Oxygen Therapy @ 2lpm Educate on indications of

via nasal cannula oxygen therapy.
Instruct not to adjust O2

concentration to avoid
depressing the drive for
breathing.
Auscultate breath sounds.
Elevate head of bed.
Encourage frequent position

changes and deep breathing
and coughing exercises.
Course in the Ward

30
July 6, 2009 To start on Bactrim Forte 1 Follow the 10 Golden Rules

Monday cap BID in administering medications.
Educate client and family on

indications, dosage and
frequency of medication.
Encourage compliance to
medications.

July 07, 2009 Received Education about Discuss home oxygen therapy
home O2 Therapy: and safety measures as
Hook to O2 @ 2lpm via indicated.
nasal cannula during the
day or as needed. Familiarize client & family
with the types of oxygen
therapy, the services
available, and the suppliers.
Evaluate the patient's and

caregiver's ability and
motivation to administer
oxygen therapy at home.
Make sure they understand
the reason why the client is
receiving O2 and safety
issues involved.
Teach them how to properly

use and clean equipment and
supplies.
31
Course in the Ward
July 07, 2009 For Discharge Instruct on home medications

including their indications,
side effects, dosage,
frequency, route of
administration.
Emphasize compliance to
medications.
Instruct on O2 therapy as
ordered.
Follow-up Check-up details
Inform of time, date and

place of follow-up.
Emphasize importance of
follow-up.
32
Proposed Surgical Therapy
Despite pharmacotherapy, pulmonary rehabilitation, and supplemental oxygen,
patients with advanced COPD typically remain very dyspneic and disabled. These relentless
symptoms have fueled many surgical attempts to treat the disease.
Further advances in surgical technique and the realization of the critical importance of
patient selection have resulted in a renewed enthusiasm for surgical treatment for COPD.
However, only three surgical therapies have stood the test of time: giant bullectomy, lung
volume reduction surgery (LVRS), and lung transplantation. Only a small number of people
with COPD, predominantly the emphysema type and not chronic bronchitis, will benefit from
two types of non-lung transplant surgery. The two major types of non-transplant surgery for
COPD are giant bullectomy and lung volume reduction surgery (LVRS).
Surgical therapy for emphysema is usually an elective procedure, and as such, all
efforts should be taken to instruct the patient in the risks of these procedures. Smoking
cessation is an absolute in the selection of appropriate candidates for these procedures.
Medical therapy should be optimized to reverse airway obstruction, bronchospasm, and
intercurrent pulmonary infections prior to surgery. A reduction or cessation of oral
corticosteroid therapy should be achieved, as these medications may be associated with poor
tissue healing. In addition, preoperatively a patient must be instructed in the techniques of
coughing, deep breathing, and chest physiotherapy. Intensive pulmonary rehabilitation prior
to the planned procedure is critical to successful outcomes following bullectomy or LVRS.
Several pulmonary function tests, cardiopulmonary exercise tests, and additional imaging
techniques are required to determine a patient’s candidacy for these surgical procedures.
Pathophysiology of Emphysema to be Corrected by Surgery
Pathophysiology
Emphysema is characterized by air-space destruction and loss of the pulmonary

capillary bed, which is needed for gas exchange (Oxygen [O2] exchanged for waste Carbon
Dioxide [CO2]). Physiologically, these changes result in the loss of elastic recoil, leading to
airflow limitation and hyperinflation. These, in turn, lead to increased work of breathing,
respiratory-muscle fatigue, and the sensation of dyspnea. Loss of the pulmonary capillaries
leads to ventilation-perfusion mismatching and increases in pulmonary vascular resistance
(pulmonary vascular pressure). In chronic severe disease, dyspnea and exercise intolerance
become very disabling for patients with emphysema. Significant mortality occurs in patients
once the forced expiratory volume in 1 second (FEV1) falls to less than 30% of predicted
values.
33
Proposed Mechanisms of Improvement
The improvements in pulmonary function reported after giant bullectomy and/or

LVRS have been attributed to increased elastic recoil, correction of ventilation-perfusion
mismatching, improved respiratory muscle efficiency, and improved right ventricular
performance. These mechanisms are not mutually exclusive, and it is likely that one or more
are operative to varying degrees in individual patients. Patients with compressed normal lung
would be expected to have increased elastic recoil and perfusion after surgery. Those with
predominantly emphysematous lung may see little improvement in these measures but may
have improved respiratory muscle function and cardiac performance due to the decrease in
lung hyperinflation. If areas of abnormal ventilation and perfusion are removed with more
areas of normal ventilation-perfusion matching remaining, dead-space ventilation will be
decreased, and arterial oxygenation (PaO2) at rest and during exercise will improve.
Reduction Pneumoplasty for Giant Bullous Emphysema
Emphysema causes alveoli air-space destruction and loss of the pulmonary capillary
bed and results in the alveoli becoming over-inflated (hyperinflated). When the
hyperinflated air sacs become extremely large, they are called bullae. Bullae are formed
from hundreds of destroyed alveoli. A bullectomy is the surgical removal of these extra-large
areas of emphysematous lung that are pressing on collapsed healthy lung, preventing those
alveoli from functioning normally. Very few individuals have these extra-large bullae that
would be amenable to surgical resection and removal, which would allow the compressed
non-emphysematous adjacent lung to function normally.
Rationale and Indications for Surgery
Bullectomy is performed to (1) relieve compressive changes in the normal lung

adjacent to a giant bulla, (2) increase compliance and airway diameter in the remaining lung,
(3) improve ventilation-perfusion matching in the nonbullous lung, (4) decrease dead-space
ventilation, (5) decrease elevated intrathoracic pressure generated by the bulla, and (6) treat
complications related to the bulla.
The decision to operate on symptomatic patients with giant bullae and otherwise
normal lung function is not difficult. More problematic is the decision to operate on patients
who are asymptomatic or on dyspneic patients with generalized emphysema. In
asymptomatic patients, surgery is indicated primarily for complications related to the bulla.
34
Bullae predispose patients to spontaneous pneumothorax (collapsed lung due to air leaks),
which may be difficult to manage due to further physiologic impairment of already limited
patients, difficulty diagnosing the pneumothorax in the presence of diffuse bullous disease,
prolonged air leaks, and a high rate of recurrence. Infection of the bullae is uncommon and
typically responds to conservative therapy, although medical therapy may be unsuccessful
due to poor communication between the bronchial tree and the bulla. Indications for surgery
are hemoptysis (coughing up blood), infected fluid in the bulla rupture into the pleural space
(chest cavity), or failure to respond to 4 to 6 weeks of antibiotic therapy. On rare occasions,
surgery may be recommended to an asymptomatic patient with a giant bulla seen by chest
radiography. Given that the natural history of untreated asymptomatic bullae is
unpredictable and poorly documented, it is generally agreed that surgery is indicated only if
the bulla occupies more than half of the hemithorax (one half of the chest cavity). In certain
patients, surgery may be indicated to reduce the risk of spontaneous pneumothorax.
In emphysema patients, it is critical to estimate the potential improvement in the
function of the nonbullous lung, as well as the effects of the bulla on the lung. Since the
rationale for surgery is the restoration of elastic recoil and the reduction of airway and
pulmonary vascular resistance, re-expansion of previously compressed lung may increase
airflow (vital capacity and FEV1). Pulmonary vascular resistance may decrease, and a
decrease in the total lung volume may restore the normal curvature of the diaphragm,
resulting in improved length-tension relationships and improved function. However, if the
patient’s symptoms are due primarily to emphysema, it is unlikely that surgery will be
beneficial.
Selection for Surgery
Clinical, Physiologic, and Radiographic Evaluation
No single preoperative variable is an absolute predictor of outcome, but several

variables (as determined by clinical, physiologic, and radiographic means) have been
postulated to predict a favorable outcome. Therefore, patients should undergo a thorough
evaluation of their overall physical conditioning, pulmonary function and reserve, and
cardiac status. This preoperative evaluation is designed to determine a patient’s overall
medical condition and his or her ability to withstand the risks of thoracotomy (open chest
surgery). Age, medical and surgical history (particularly of thoracic trauma or surgery),
comorbid diseases, chronic bronchitis, cardiac status, smoking history, and unexplained
weight loss are all important predictors of outcome. Once a patient has been selected for
35
surgery, optimization of medical therapy (including aggressive rehabilitation, physical
therapy, and smoking cessation) may reduce postoperative risk and improve pulmonary
function.
Selection Criteria for Bullectomy: Predictors of Outcomes

Clinical Parameter Good Outcome Poor Outcome
Age < 50 yr > 50 yr

Comorbid Disease None Present
Cardiac Status Normal Right Ventricular Failure
Weight Loss < 10% > 10%
Dyspnea Rapidly progressive Slowly progressive
PFTs
Spirometry Normal - Mild Decrease Markedly Decreased
Diffusion Normal Decreased
Arterial Oxygen (PaO2) Normal Hypoxemia
Arterial CO2 (PaCO2) Normal Increased
Lung Imaging
CXR Bulla > 1/3 hemithorax Diffuse multiple small bullae
CT Large localized bullae Multiple bilateral bullae
V/Q scan Matched defect Diffuse defects
Bullectomy Surgical Techniques
In general, the bullectomy procedure aims to relieve compression while preserving all
vascularized and potentially functioning lung tissue. This is best accomplished by limited
resections such as local excision, plication (folding out) of the bulla, or both. A variety of
approaches have been described, including unilateral thoracotomy or video-assisted
thoracoscopic surgery (VATS). For patients with bilateral disease, exposure is gained via
bilateral posterolateral thoracotomy or bilateral anterolateral thoracotomy (with or without
transverse sternotomy) or through a median sternotomy. All have been advocated, and each
36
has its own advantages and disadvantages. Other surgeons prefer a two-stage bilateral
procedure, which allows functional assessment of the first procedure before proceeding with
the contralateral procedure. In general, bilateral procedures should be limited to patients
without severe emphysema, with the bullectomy done first on the lesser-functioning lung as
determined by preoperative physiologic and imaging studies. The final operative results may
be adversely affected by persistent postoperative air spaces and prolonged air leaks. These
may be limited by the use of pleural tents or buttressed staple lines with bovine pericardium.
Lung Volume Reduction Surgery
The preoperative evaluation of the potential LVRS candidate should include

pulmonary-function tests, with assessment of lung volume and diffusion capacity, inspiratory
and expiratory chest radiography, CT scan of the chest, assessment by arterial blood gases, a
6-minute walk test, quantitative ventilation-perfusion (V/Q) lung scanning, cardiac, and
psychosocial evaluations.
Pulmonary-function testing should be the initial screening test for evaluating
candidates for LVRS. Spirometry determines the degree of airflow limitation and whether
there is a significant reversible component consistent with reactive airways disease. Lung
volumes should be measured by body plethysmography, to accurately assess the volume of
trapped gas and the residual lung volumes. Diffusion capacity evaluates the severity of the
destruction of the alveolar capillary bed. Arterial blood gases are indicative of the level of
pulmonary reserve, with either severe hypoxemia (low O2) or hypercapnia (high CO2)
representing severe lung tissue destruction. The 6-minute walk test provides insight into the
level of a patient’s functional reserve.
Inspiratory and expiratory chest radiography provides useful information about the
degree of hyperinflation, the position of the diaphragm, and the presence of chest wall
abnormalities. Computed tomography (CT) scans provide information on the degree of
heterogeneity, the location of so-called target areas, and the severity of lung tissue
destruction. Quantitative ventilation-perfusion (V/Q) lung scans also provide information on
heterogeneity and the function of the remaining lung tissue .
Cardiac evaluation typically consists of a history, physical examination,
electrocardiography, and echocardiography to assess left and right ventricular function and to
estimate pulmonary artery pressures. Right heart catheterization is performed in patients
with evidence of pulmonary hypertension on echocardiography. In patients with multiple
37
coronary risk factors or a prior history of coronary artery disease, a nuclear stress test, or left
heart catheterization is indicated.

Inclusion and Exclusion Criteria
The inclusion criteria were developed to enroll patients with emphysema with diverse
patterns of distribution, to determine whether anatomic emphysema distribution affects the
response to therapy. Mandatory inclusion criteria include radiographic evidence of
emphysema, evidence of severe airflow obstruction and hyperinflation on pulmonary-
function tests, and the ability to participate in and achieve preset goals of pulmonary
rehabilitation. The exclusion criteria were designed to exclude patients at risk for
perioperative morbidity and mortality, patients with obstructive disease not suitable for
LVRS, and patients with comorbid conditions that would prevent those patients from
completing the trial.
Inclusion Criteria
History and Physical Examination consistent with Emphysema
Disabling Dyspnea
CT scan evidence of bilateral emphysema
Spirometry Airflow Limitation (FEV1 < 45% Predicted Value)
Lung Volume Hyperinflation by PFT
Pre-rehabilitation Room Air Resting PaO2 > 45 mm Hg and PaCO2 < 60 mm Hg
Nonsmoker for 4 months
Adherence to Medical Therapy
Non-Obese – Body Mass Index < 30
Approval for Surgery by Cardiologist if evaluation suggestive of cardiac disease
Completion of all pre-rehabilitation assessments
Completion of NETT rehabilitation program
Ongoing disabling symptoms following completion of pulmonary rehabilitation
Approval for LVRS by Pulmonary Physician and Thoracic Surgeon
Consent for LVRS
Exclusion Criteria
Severe Emphysema, FEV1 < 20% predicted value and/or Diffusion (DLCO) < 20%
Non-heterogeneous Emphysema by CT scan
Severe hypoxia (Room Air PaO2 < 45mm Hg) or hypercarbia (PaCO2 > 60mm Hg)
Inability to provide diffusion (DLCO) measurement
38
Six-minute walk distance < 140 meters post-rehabilitation

CT scan of diffuse emphysema unsuitable for LVRS
Prior thoracic surgery that would interfere with lung resection
Pleural or Interstitial Lung Disease (ILD)
Giant bullae (> 1/3 Volume of the Lung)
Mucous hyperexcretion or Significant Bronchiectasis
Myocardial Infarction or Congestive Heart Failure within 6 months
Uncontrolled Systemic Hypertension
Pulmonary Hypertension
Severe Obesity or Malnutrition
Prednisone usage > 20 mg/day
Poor functional capacity due to non-pulmonary disease
Systemic diseases which limits survival (e.g. cancer)
LVRS Operative Techniques
The overall goal of LVRS resection is to decrease the volume of both lungs by 20%
to 35%. The use of bovine pericardial strips to buttress the staple lines decreases the
incidence, duration, and severity of air leaks. Most authorities now consider the stapled
procedure, with or without buttressing, to be the technique of choice for LVRS. A number of
approaches for stapled resections have been advocated, including median sternotomy,
thoracotomy, clamshell incision, and VATS, but the choice of one procedure over another
has generally been a matter of personal preference of the surgeon.
Intraoperative and Postoperative Management
Intraoperatively, care must be taken to avoid overdistension of the lungs due to

positive pressure ventilation. This may result in impaired venous return, decreased cardiac
output, and cause hypotension. Excessive hyperinflation may also result in tension
pneumothorax (collapsed lung pressing on the heart and great vessels) due to rupture of a
bleb, bulla, or emphysematous tissue. Despite the presence of hypercarbia and hypoxemia,
permissive hypercapnic ventilation is allowed and, if necessary, the patient is removed from
the ventilator circuit to allow adequate exhalation and decompression. Peak airway pressure
should be limited to less than 30 mm Hg, and the inspiratory/expiratory ratio should be as
39
great as possible. Patients are intubated (breathing tube inserted and patient placed on a
ventilator) with double-lumen endotracheal tubes (breathing tubes). The use of long-acting

narcotics or anesthetics is avoided to facilitate early extubation (removal of breathing tube) at
the end of the procedure. Prior to extubation, patients undergo fiberoptic bronchoscopy to
remove blood and secretions and to obtain material for cultures. Almost all patients are
extubated at the end of the procedure or shortly thereafter, thus limiting the exposure to
positive pressure and decreasing the severity of any air leaks from the staple lines. Routine
chest tube suction is not employed except in the case of large pneumothoraces or persistent
large air leaks .
Adequate pain control is initially achieved by the use of a thoracic (chest) epidural
catheter. Later, the patients receive patient-controlled analgesia with narcotics. This
approach may decrease gastrointestinal complications and allows for aggressive respiratory
therapy, chest physiotherapy, and physical therapy. Respiratory care includes breathing
exercises, inhaled bronchodilators, and early mobilization. Instruction in these techniques is
given preoperatively to all patients. Routine monitoring of oxygen saturation, blood
pressure, heart rate, temperature, and urine output is performed for the first few postoperative
days. A stress dose of corticosteroids is given to those patients who were steroid dependent
preoperatively. Antibiotic prophylaxis directed against respiratory tract organisms common
to COPD patients (pending bronchoscopic cultures), gastric ulcer prophylaxis, and
subcutaneous heparin or pneumatic stockings for deep venous thrombosis prophylaxis are
used in all patients .
40
Laboratory and Diagnostic
Results
PULMONARY FUNCTION TEST/SPIROMETRY
(No data available on Mr. P 's record)
General information
Where It is Done Who Does It How Long It Takes Discomfort/Pain
Doctor's office, Doctor, respiratory

commercial pulmonary therapist, or
20-45 minutes. Test can be tiring.
function laboratory, or pulmonary lab
hospital. technician.
Special Equipment Risks/Complications

Results Ready When
May aggravate symptoms of lung disease.

Should not be performed in people with
Pulmonary function
Several hours to a few unstable asthma or respiratory distress, recent
analyzer (usually
days. heart attack or unstable heart disease,
includes a spirometer).
pneumothorax, coughing up large amounts of
blood, or active tuberculosis.
Purpose
• To assess the ability of the lungs to receive, hold, and use air.
• To evaluate the severity of lung disease.
• To distinguish between restrictive and obstructive lung disease.
• To monitor the course of lung disease.
41
• To monitor the effectiveness of treatment.
Diagnostic and Laboratory

Results
How it works
The volume of air the client exhales through a tube can be measured with a device
called a spirometer, and is an indication of how well your lungs are functioning.
Preparation
 Client must refrain from smoking or heavy eating for four to eight hours before the
test.
 If possible, avoid using bronchodilators or other drugs for 24 hours prior to the test or
as specified by your doctor before this test.
 Wear loose, comfortable clothing that does not restrict breathing.
 Client's age, sex, height, and weight are recorded in order to calculate expected test
values.
 A clip is placed on client's nose to prevent the air from escaping through the nostrils.
 Loose-fitting dentures may be removed.
Test procedure
 Client puts a mouthpiece (made of

cardboard or rubber, depending on
the test) in your mouth and breathe
normally while the technician makes
sure the equipment is functioning
properly (see figure).
 Client performs various breathing
maneuvers: taking a deep breath,
holding it briefly, and forcefully
blowing the air out through the
mouthpiece, which is attached to a
flexible tube that leads to the
spirometer.
 These tests are usually repeated at
least three times to make sure similar
42
values are obtained at each attempt. Values that vary widely may indicate a technical
problem.
 Various measurements are taken of the volume of air that the client is able to inhale
and exhale. The ability of his lungs to deliver oxygen to blood may be measured by
inhaling one breath of air with a high concentration of carbon monoxide.

Results
During pulmonary function tests (spirometry), the patient is asked to perform various
breathing maneuvers by exhaling into a special mouthpiece attached to monitoring
equipment.
Factors affecting results
 Failure to follow instructions, such as not exhaling with maximum force.

 Anxiety or fatigue.
 Recent or current respiratory disease.
 Bronchodilators, sedatives, and other drugs that affect breathing or all body systems.
 Other procedures performed a few hours before the test, such as positive-pressure-
breathing therapy.
 Time of day: pulmonary function tends to rise and then fall from morning to evening.
 Portable spirometers used at bedside tend to be less reliable than stationary
spirometry equipment.
Interpretation
The test results, printed out as a table or a graph, are compared with average values
for the patient’s age, sex, height, and weight.
CHEST X-RAY
Date: June 18, 2009 and July 01, 2009
Chest Portable
Seven (7) serial follow-up chest films dated June 18 to July 1, 2009 since June 17,
2009 show progression of pulmonary congestion to edema on June 29, 2009 with partial
clearing in the follow-up films until the last film.
43
There is development of bilateral pleural effusion on June 22, 2009 with clearing on
June 26, 2009 and reprogression on June 28, 2009 and clearing in the last film.
The last film shows:
Prominent main pulmonary artery segment

Endotracheal tube was removed.
No other remarkable findings.

Results
Nursing Responsibilities:
 Check the doctor’s order.
 Explain the procedure to the patient.
 Before the chest X-ray, let the patient undress from the waist up and wear an
exam gown. Remove jewelry from the waist up, since both clothing and
jewelry can obscure the X-ray images.
 Instruct the patient to hold his arms up or to the sides and roll his shoulders
forward. Let him take a deep breath and hold it for several seconds while the
X-ray image is taken. Letting him hold his breath after inhaling helps his heart
and lungs show up more clearly on the image.
44
ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER
Indication
Echocardiography is a painless test that uses sound waves to create images of your
heart. It provides your doctor with information about the size and shape of your heart and
how well your heart’s chambers and valves are working.
The test also can identify areas of heart muscle that aren’t contracting normally due to
poor blood flow or injury. In addition, a type of echocardiography called Doppler ultrasound
shows how well blood flows through the chambers and valves of your heart.
Echocardiography can detect possible blood clots inside the heart, fluid buildup in the sac
around the heart (pericardium), and problems with the aorta.
Conclusion:
 Moderate tricuspid regurgitation
 Mild pulmonary hypertension
 Explain the procedure in detail, including possible complications and side

effects to the patient.
 Explain that the technician will need to see his chest from the waist up.
Privacy will be maintained by drapes across his chest and by limiting access
into the procedure area.
 EKG electrodes will be attached to his chest with adhesive patches.
45
Results
 Position patient on supine during the procedure. A pillow or wedge may be
placed behind his back for support.
 The room will be darkened so that the images on the echo monitor can be
better viewed by the technician.
 Place gel on his chest and then place the transducer probe on the gel. Explain
to the patient that he will feel a slight pressure as the technician positions the
transducer to get the desired image of his heart.
 During the test, the technician will move the transducer probe around and
apply varying amounts of pressure to obtain images of different locations and
structures of his heart. The amount of pressure behind the probe should not be
uncomfortable, but if it makes him uncomfortable, instruct him to let you or
the technician know.
 After the procedure has been completed, wipe the gel from his chest and
remove the EKG electrodes.
ENDOTRACHEAL ASPIRATE C/S WITH GRAM STAINING
Date Collected : June 29, 2009

Gram Stain : >25 pus cells per lpf
<25 squamous epithelial cells/lpf
Occasional gram positive cocci singly
Occasional gram negative bacilli
Culture : Heavy growth – Staphylococcus aureus
Indications:
A culture is done to find out what kind of organism is causing an illness or infection.
A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work
best to treat the illness or infection.
46
Gram staining is a common procedure in the traditional bacteriological laboratory.
The technique is used as a tool for the differentiation of Gram-positive and Gram-negative
bacteria, as a first step to determine identity of a particular bacterial sample.
Interpretation and Significance of Results:
Result shows that there is presence of bacterial growth in the sputum of theMr. P.
This test helps in determining what type of antibiotic will be use for the proper treatment of
the infection.

Results
 Check doctors order.
 Explain the procedure to patient.
 Observe proper precaution in collecting the sample.
 Maintained sterile technique.
 Observed proper hand washing before and after the procedure.
 Label the specimen cup with patient’s data.
HEMATOLOGY
Complete Blood Count
RESULTS NORMAL
47
June 17 June 22 June 23 June 28 June 29 VALUES
RBC 4.50-5.20
5.43 H 5.24 H 5.43 H 5.94 H 5.82 H
1012/L
Hemoglobin 168 157 164 184 H 176 H 140-170 g/L
Hematocrit 0.53 H 0.48 0.49 0.54 H 0.53 H 0.42-0.51 g/L
WBC 9.50 7.50 12.90 H 25.00 H 23.90 H 5-10 109/L
Platelet
200 262 225 431 H 477 H 200-400 109/L
Count
Differential Count
RESULTS
NORMAL VALUES
June 23 June 29
Neutrophil 91% H 92% H 55-65%
Lymphocyte 4% L 3% L 25-35%
Monocyte 5% 5% 2-6%
Indications:
The CBC is a combination report of series of tests of the peripheral blood. The
quantity, percentage, variety, concentrations, and quality of blood cells are identified.
48
Results
Mr. P's RBC, Hgb, Hct show an increased value. RBC are responsible for picking up of
oxygen from the lungs and delivers it to tissues and to pick up carbon dioxide from other
tissues and unload it in the lungs, due to the inflammation and trapping of air in the alveoli,
there is impaired gas exchange. The body will sense that there is a decreased in circulating
oxygen, as a compensatory mechanism, the body will produce more RBC through
erythropoiesis thus increasing the RBC count.
WBC count value is high signifies there is a possible infection or an inflammation. In

emphysema, there is inflammation of the alveoli showing an increased in the number of
WBC and platelet count as well.
With regards to the Differential count, an increased in the number of neutrophils

suggests there is a bacterial infection. Neutrophils are also the first to respond with
inflammation. A low lymphocyte count may be due to use of steroids in the treatment and
therapy for the client.
Prior to:

 Explain the procedure to the patient that this test evaluates the blood for the
presence or absence of infection in the body, the body’s defense against
infection, the number and condition of RBC in the body, and the presence or
absence of anemia.
 Inform the patient that this test does not need to restrict foods or fluids before
the test.
During:
49
 Tell the patient that he may experience discomfort due to the needle puncture.
 Reassure the patient that collecting the sample will take less than a minute.
 Apply cotton on the puncture site.
After:
 Apply pressure to the venipuncture site using cotton.

 If hematoma develops at the venipucture site, apply warm compress.
 Observe and report the test result to the attending physician, and monitor
status of the patient.
 Check for signs and symptoms of infection.

Results
BLOOD CHEMISTRY – Serum Electrolytes
RESULTS NORMAL
June 17 June 21 June 22 June 28 June 29 July 04 VALUES
Potassium 5.2 H 3.5-4.8

4.5 4.2 4.5 5.4 H 5.1 H
mEq/L
Indications:
This blood test check electrolytes, the minerals that help keep the body's fluid levels
in balance, and are necessary to help the muscles, heart, and other organs work properly. To
assess kidney function as well.
50
Upon admission, it shows that result is within the normal limits but goes slightly
elevated during the course of confinement. Since the client is also hypertensive, one of many
drugs used in treating HTN is the use of diuretics, close monitoring of serum potassium is
needed, as well as ECG readings.
Prior to:

the test.
During:
After:

 Observe and report the test result to the attending physician, and monitor
status of the patient. Check for ECG readings, heart beats, muscle strength and
weakness.

Results
CLINICAL CHEMISTRY – TP/AG RATIO
51
RESULTS
NORMAL VALUES
June 22 June 23
Total Protein 60.0 L - 65-83 g/L
Albumin 32.0 L 33 40-50 g/L
Globulin 28.0 - 26-36 g/L
A/G Ratio 1.14 - 1.00-2.00
Indications:
A total serum protein test measures the total amount of protein in the blood. It also
measures the amounts of two major groups of proteins in the blood: albumin and globulin.
Albumin is made mainly in the liver. It helps keep the blood from leaking out of
blood vessels. Albumin also helps carry some medicines and other substances through the
blood and is important for tissue growth and healing.
Globulin is made up of different proteins called alpha, beta, and gamma types. Some
globulins are made by the liver, while others are made by the immune system. Certain
globulins bind with hemoglobin. Other globulins transport metals, such as iron, in the blood
and help fight infection.
There is a low value of total protein and albumin in client’s blood serum, indicating
decreased renal function, although there’s no albumin leaking in his urine since the level of
serum albumin is not that significantly low and also patient is on acute disease state that may
also aggravate the condition. Hypoalbuminemia causes decrease oncotic pressure resulting
to edema.
Prior to:
52
the test.
During:

Results
After:

 Monitor patient’s weight.
 Assess for presence of edema.
CLINICAL MICROSCOPY – Urinalysis
GROSS EXAMINATION
Physical Analysis RESULTS - June 23 Reference Range

Color Yellow Yellow
Transparency Turbid Clear
Specific Gravity 1.005 1.015 – 1.025
Chemical Analysis
pH 9.0 4.6
Protein Negative Negative
Sugar (Glucose) +1 Negative
Bilirubin Negative Negative
Urobilirubin Negative Negative
Blood +3 Negative
Nitrites Negative Negative
Leukocytes Negative Negative
53
Ketone (Acetone) Negative Negative
Ascorbic Acid Negative Negative
AUTOMATED URINE MICROSCOPY ANALYSIS

(Flow-Imaging Microscopy and Auto-Particle Recognition)
RESULTS – June 23 Reference Range

(/ul) (/hpf) (/ul) (/hpf)
RBC 1346 245 ≤ 17 ≤3
WBC 17 3 ≤ 28 ≤5
Bacteria Occasional Negative
Epithelial Cells Occasional Negative

Results
Indications:
Urinalysis is the physical, chemical, and microscopic examination of urine. It

involves a number of tests to detect and measure various compounds that pass through the
urine.
Result reveals alkalinity of client’s urine, a presence of glucose and blood in the urine
in the gross examination. The pH of urine is an indication of the kidney's ability to maintain a
normal plasma pH. Since our client is diabetic, there is presence of glucose in the urine.
54
Increase RBC is present since our client has DM nephropathy leading to glomerular
damage.turbidity is due to increase RBC in urine.
55
Diagnostic and Laboratory Results
ARTERIAL BLOOD GAS
DATE TIME VENTILATOR pH PCO2 PO2 HCO3 CO2 BE O2 INTERPRETATION

SET-UP SAT
6/21/09 6AM 7.36 67 52 37 39 8.4 84.4% Fully Compensated

Respiratory Acidosis with
Severe Hypoxemia
6/21/09 4:15AM 7.30 76 117 36 38 6.4 97.7% Partially Compensated
More than Adequate
Oxygenation
6/22/09 3:11AM FiO2=60% 7.22 90 95 36 39 4.8 95.3% Partially Compensated
Adequate Oxygenation
6/22/09 7.37 67 53 38 40 9.8 85.3% Fully Compensated
Severe Hypoxemia
6/24/09 7.41 55 48 34 35 7.1 95.4% Fully Compensated Metabolic
Alkalosis with Severe
Hypoxemia
6/25/09 4:30PM 7.46 48 53 33 35 8.1 88.6% Partially Compensated
Metabolic Alkalosis with
Severe Hypoxemia
56
DATE TIME VENTILATOR pH PCO2 PO2 HCO3 CO2 BE O2 INTERPRETATION

SET-UP SAT
6/26/09 7.42 53 60 34 35 7.6 91.6% Fully Compensated Metabolic

Alkalosis with moderate
hypoxemia
6/27/09 12NN 7.42 46 58 29 30 3.6 90.2% Fully Compensated Metabolic
Alkalosis with Severe
Hypoxemia
6/29/09 7.41 51 77 31 33 5.3 95% Fully Compensated Metabolic
Alkalosis with Moderate
Hypoxemia
6/30/09 7.32 51 80 30 34 6.2 93% Partial Compensated
mild hypoxemia
7/1/09 7.38 50 78 27 36 5.7 94% Fully Compensated
Adequate Oxygenation
7/02/09 7.41 52 81 26 35 7.6 95% Uncompensated Metabolic
Alkalosis with Mild
Hypoxemia
57
Arterial Blood Gases Analysis
An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood. This test
is used to check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.
As blood passes through your lungs, oxygen moves into the blood while carbon dioxide moves out of the blood into the lungs.
An ABG test uses blood drawn from an artery, where the oxygen and carbon dioxide levels can be measured before they enter body
tissues.
Patient’s Value: During the Mr. P’s stay, serial blood gases analysis were done, to monitor his level of oxygenation.
Interpretation:
The differences in Mr. P’s blood gases interpretation are dependent on factors which have a significant effect on ventilation
and perfusion process. The values show that Mr. P has been experiencing episodes of hypoxemia. This correlates with the disease
process on which there is an airflow limitation. ABG results that show respiratory acidosis signify that Mr. P has a decreased capacity
for carbon dioxide (CO2) elimination.
 Inform the patient of the procedure and its significance.
 Inform Respiratory Therapist the time of the last nebulization. Procedure should be done 30 minutes after nebulization.
 Follow-up and relay results to the doctor.
58
Drug Study
Generic Name: Salmeterol Xinafoate Brand Name : Seretide
Classification: Sympathomimetics Date Started : June 17, 2009
Mechanism of Action Dose/Route Contraindications Nursing Responsibilities Patient/Family
Teaching
 Not clearly -1 inhalation 2x a day  Use cautiously  Drug isn’t indicated  Instruct Mr. P
defined. Selected in patient for acute and his family
activates beta₂ unusually bronchospasm. never wash the
receptors which responsive to  Monitor Mr. P for mouth piece or
results in sympathomimetics rash and urticaria, any part of the
bronchodilation; and those with which may signal a dry-powder multi-
also blocs the coronary hypersensitivity dose inhaler; it
release of allergic insufficiency, reaction. must be kept dry.
mediators from arrhythmias,
mast cells lining the hypertension, after
respiratory tract. CV disorders,
thyrotoxicosis or
Indications: seizure disorders.
 Long term
maintenance of
asthma and
obstructive airway
disease who need
regular treatment
with short acting
beta-antagonists.
59
Drug Study
Generic Name: Cefuroxime sodium Brand Name : Zinacef
Classification: Cephalosporin Date Started : June 17, 2009
Mechanism of Dose/Route Contraindications Nursing Responsibilities Patient/Family
Action Teaching
 Second -750 mg q 6  Contraindicated in  Before  Instruct to take
generation hours patient hypersensitive administration ask Mr. drug after food.
cephalosporine to cephalosporin. P if he is allergic to  Tell Mr. P to
that inhibits  Used cautiously in penicillin or notify physician
cell-wall patients hypersensitive cephalosporin. about loose stools or
synthesis, to penicillin because of  Obtain C/S before diarrhea.
promoting possibility of cross giving the first dose.
osmotic sensitivity with other  Absorption of
instability beta-lactams cefuroxime is enhanced
usually antibiotics. by food.
bacterial.  Use cautiously in
patient with history of
colitis or renal
insufficiency.
60
Drug Study
Generic Name: Digoxin Brand Name : Lanoxin
Classification: Cardiac Glycosides Date Started : June 17, 2009
Teaching
 Increase .25 mg 1 tablet OD  Intermittent complete  Monitor apical  Instruct
contractility of the heart block or 2nd-degree pulse for one full minute Mr. P to take
myocardium by AV block, especially if before administering. medication
direct activity. there is a history of  Withhold dose and exactly as
Stroke-Adams attack. notify physician if pulse directed, at the
Indications:  Arrythmias caused by rate is less than 60 bpm same time each
cardiac glycoside in an adult. Notify day; do not
 Cardiac intoxication. physician of any double dose.
Failure:  Ventricular tachycardia significant changes in Missed doses
 Management or ventricular fibrillation. rate, rhythm or quality should be
of chronic cardiac of pulse. taken within 12
failure where the Special Precaution:  Notify the physician hours of
dominant problem bradycardia or new scheduled dose
is systolic  Caution in patients arrhythmias occur. or not taken at
dysfunction. with ischemic heart  Monitor I/O daily all.
disease, acute myocarditis, weight. Assess for  Do not
 It is cyanotic heart and lung peripheral edema and discontinue
specifically disease auscultate lungs for medication
indicated where rales/crackles without
cardiac failure is throughout therapy. consulting the
accompanied by  If hypokalemia is doctor.
atrial fibrillation. present and renal  Review
function is adequate, signs and
potassium salts maybe symptoms of
61
administered. Do not toxicity with
administer if Mr. P and his
hyperkalemia or heart family.
block exists.  Advise Mr.
P to take
antacids or
anti-diarrheal
within two
hours of taking
Digoxin.
62
Drug Study
Generic Name: Zocor Brand Name : Simvastatin
Classification: Cardiovascular System Drugs Date Started : June 17, 2009
Teaching
 Inhibits HMG- -40 mg 1 tab OD Contraindicated in patient  Obtain liver function  Instruct Mr. P
CoA with patients test result as a start of to take drug with
 Reductase, an hypersensitivity to drug therapy. the evening meal
early step in and in those with active  Simvastatin 40 mg because taking
cholesterol liver disease or conditions daily significantly this enhances
biosynthesis that cause unexplained reduces risk of death absorption and
persistent elevations of from coronary heart increase
transaminase level. disease. cholesterol
biosynthesis.
 Teach him
about proper
dietary
management of
cholesterol and
triglycerides
when
appropriate,
recommend
weight control,
exercise, and
smoking
cessation
program.
63
Drug Study
Generic Name: Methylprednisone sodium succinate Brand Name : Solu-Medrol
Classification: Corticocosteroid Date Started : June 18, 2009
Mechanism of Dose/Route Contraindications Nursing Responsibilities Patient/Family Teaching
Action
 Decrease 40 mg/IV q 6  Hypersensitivity to  Dose must be  Take exactly as
inflammation hours drug individualized directed
mainly by  Document  Do not incorporate
stabilizing Special Precaution: indication for or suddenly stop
leukocyte lysomal treatment; describe taking after prolonged
membranes  HPN clinical presentations use without provider’s
 Suppress  DM  Monitor v/s, consent; may cause
immune response weight, CBC HbA1c, rebound
Adverse Reactions: glucose, renal/LFTs, symptoms/adrenal
GI upset, septic necrosis of TFTs, cholesterol, and crisis.
femoral and humeral heads, electrolytes  If administered
peptic ulceration, before 9 AM, may
anaphylactic reaction, cardiac mimic normal peak
arrest or arrhythmias, body corticosteroid
bronchospasm, and also prevent
insomnia
 Report any
unusual weight gain
extremity swelling,
fatigue, nausea,
anorexia, joint pain,
muscle weakness,
dizziness, fever, black
or tarry stool
64
Drug Study
Generic Name: Pulmicort Turbohaler Brand Name : Budesonide
Classification: Inhaled Steroids Date Started : June 18, 2009
Mechanism of Action Dose/ Route Contraindications Nursing Responsibilities Patient/Family
Teaching
 Anti- 1 tab q 12 hours  Contraindicated  Corticosteroids may  Tell Mr. P
inflammatory in patients increase risk of that
corticosteroid that hypersensitive to developing serious or budesomide
exhibit potent drug and in those fatal infections especially inhaler isn’t a
glucocorticoid with status when exposed to viral bronchodilator
activity and weak asthmaticus or other illness, such as chicken and isn’t
mineralo- acute asthma pox. intended to
corticosteroid episodes.  Tell patient to stop treat acute
activity. drugs if local irritation episodes of
occurs. asthma.
 Tell him to
keep Pulmicort
turbuinhaler
upright during
loading to
provide the
correct dose.
 Replace
mouth piece
cover after use
and always
keep it clean
and dry.
65
Drug Study
Generic Name: Ertapenem Sodium Brand Name : Invanz
Classification: Antibiotics/Beta-Lactam Date Started : June 18, 2009
Action Teaching
 Inhibits cell 1 g IV OD  Hypersensitivit  Check for previous  Inform Mr. P of
wall synthesis y to ertapenum or penicillin cephalosporin, potential adverse
through in patients who or other beta-lactam reaction.
Penicillin-binding have demonstrated hypersensitivity before  Tell him to alert
proteins anaphylactic giving first dose. nurse if discomfort
reaction to B-  Check for occurs at injection.
Lactams. IM hypersensitivity to local Site.
hypersensitivity to anesthesia of the amide
lidocaine or local type if giving dose IM
anesthesia of the
amidetype; severe
shock, heart block
66
Drug Study
Generic Name: Isosorbide dinitrate Brand Name : Isordil
Classification: Anti-anginal Date Started : June 18, 2009
Action Teaching
 Not 1 tab S.L. for  Contraindicated  Monitor blood  Advise Mr. P,
completely single dose in patient with pressure and intensity who might complain
known. Though hypersensitivity on and duration of drug of tingling sensation
to reduce cardiac idiosyncrasy to dose. with S.L. drug to try
oxygen demand nitrate.  Drug may cause holding tablet in
by decreasing  Use cautiously in headaches, especially cheek.
pre-load and patient with blood at beginning of  Tell him to
afterload. Drug volume depletion therapy. Dosage may minimize dizziness
may also (such as from be reduced temporarily upon standing up by
increase blood diuretic therapy) or but tolerance usually changing to upright
flow through the mild hypotension. develops. Treat position slowly.
collateral headache with aspirin
coronary or acetaminophen.
vessels.  Methemoglobinemi
a has been with
Indications: nitrates. Symptoms are
those of impaired
 Acute angina oxygen delivery
attacks (S.L. despite adequate
Isosorbide cardiac output and
Dinitrate only); adequate arterial partial
to prevent pressure of oxygen.
situations that
67
may cause
angina attacks.
Drug Study
Generic Name: Spironolactone Brand Name : Aldactone
Classification: Diuretics Date Started : June 19, 2009
Action Teaching
 Potassium- 50 mg 1 tab once a  Contraindication  To enhance  To prevent
sparing diuretic; day in patient absorption, give drug periodic
antagonizes hypersensitive to with meals. hyperkalemia,
aldosterone in drug.  Protect drug from educate Mr. P to
the distal  Contraindicated light. avoid excessive
tubules, in those with anuria,  Monitor intake of
increasing acute or progressive electrolyte level, fluid potassium-rich
sodium and renal insufficiency, intake and output, foods (such as
water excretion. or hyperkalemia. weight and blood citrus fruits,
pressure. tomatoes, banana,
Indications: dates and apricot),
potassium
 Edema, containing salt
hypertension substitutes and
 Diuretics- potassium
induced supplements.
hypokalemia
68
Drug Study
Generic Name: Azithromycin Brand Name : Zithromax
Classification: Macrolides Date Started : June 19, 2009
Teaching
 Binds to the 5 -500 mg 1 tab twice a  Contraindicated  Obtain specimen for  Tell Mr. P
os subunit of day in patients culture and sensitivity that tablets may be
bacterial hypersensitive to test before giving first taken with or
ribosomes every erythromycin dose. Therapy may begin without food.
blocking protein or other macrolides. pending results.  Tell him to
synthesis;  Use cautiously  Give multidose oral take the drugs even
bacteriostatic or in patient with suspension 1 hour before after he feels
bactericidal impaired hepatic or 2 hours after meals; better.
depending on the function. don’t give with antacids.
situation.  MonitorMr. P for
superinfection. Drug may
Indications: cause over growth of
non-susceptible bacteria
 Acute bacterial or fungi.
worsening of
COPD.
69
Drug Study
Generic Name: Glimepiride Brand Name : Solosa
Classification: Oral antidiabetic agents Date Started : June 21, 2009
Action Teaching
 Unknown. -3 mg 1 tab ½ tab once  Contraindicated  Monitor FBS  Tell Mr. P to
Lower glucose a day with patient regularly to determine tae drug with first
level, possibly hypersensitive to therapeutic response. meals of the day.
by stimulating Indications: drug and in those  Use of oral  Advise him to
release of with diabetic hypoglycemic may avoid alcohol,
insulin from Adjust to diet and ketoacidosis, which carry higher risk of which lower
functioning exercise to lower should be treated CV mortality than use glucose level.
pancreatic beta glucose level in with insulin. of diet alone as of diet
cells, and may patient with type II  Use cautiously and insulin therapy.
lead to increased (non-insulin in patient allergic
sensitivity of dependent) diabetes to sulfonamides.
peripheral tissue whose hyperglycemia
to insulin. can’t be managed by
diet and exercise
alone.
70
Drug Study
Generic Name: Metformin Hydrochloride Brand Name : Glucophage
Classification: Antidiabetics Date Started : June 21, 2009
Teaching
 Decrease 500 mg 1 tab, ½ tab  Contraindicated  Monitor Mr. P’s
hepatic glucose twice a day in patient glucose level regularly  Instruct Mr.
production and hypersensitive to to evaluate effectiveness P about nature
intestinal drug. of therapy. Notify of diabetic and
absorption of  Use caution prescriber of glucose importance of
glucose and when giving drug level increase despite following
improves insulin to elderly therapy. therapeutic
sensitivity debilitated, on  Give with meals; regime.
(increase malnourished give once daily dosage
peripheral uptake, patient and to with breakfast and twice
glucose are used. those with adrenal daily dosage with
or pituitary breakfast and dinner.
insufficiency  Monitor glucose
because of level prior to giving of
increased risk of drugs.
hypoglycemia.
71
Drug Study
Generic Name: Pantoprazole Brand Name : Ulcepraz
Classification: Proton Pump Inhibitor Date Started : June 22, 2009
Teaching
 Inhibits proton -40 mg IV once a day  Contraindicate  Stop treatment with  Instruct Mr. P
pump activity by d in patient IV pantoprazole when to take exactly as
binding to hypersensitive to P.O. form is warranted. prescribed and at
hydrogen- any component of  Drug can be given about the same
potassium the formulation. without regard to time every day.
adenosine meals.  Tell him that
triphospatase antacids don’t
located at secretory affect
surface of gastric pantoprazole
parietal cells, to absorption.
suppressed gastric
acid secretion.
Indications:
 Prevention of
gastro-duodenal
ulcers induced by
NSAID in patient at
risk with a need for
long term NSAID
therapy, duodenal
and gastric ulcers
reflux esophagitis.
72
Drug Study
Generic Name: Valium Brand Name : Diazepam
Classification: Antianxiety Date Started : June 22, 2009
Teaching
 Unknown. A -5 mg 1 IV  Contraindicated in  Use of this drug may  Instruct Mr. P
benzodiazepine patient hypersensitive lead to abuse and about the signs and
that probably to drug or soy protein. addiction. Don’t symptoms of early
potentiates the Use cautiously in withdraw drug abruptly adrenal
effects of GABA, patient with liver or after long term use. insufficiency;
depressed the renal impairment, Withdrawal symptoms fatigue, muscle
CNS, and depression, or chronic may occur. weakness, joint
suppresses the open-angle glaucoma. pain, fever,
spread of seizure Use cautiously in anorexia, nausea,
activity. elderly and debilitated SOB, dizziness
patients. and fainting.
Indications:
 Adjunct
treatment for
seizure disorders
73
Drug Study
Generic Name: Ceftazidime Brand Name : Fortum
Classification: Antibiotics Date Started : June 22, 2009
Teaching
 Third -1 gm IV every 8  Contraindicated  Before  Tell Mr. P to
generation hours in patient administration, ask report adverse
cephalosporine hypersensitive to Mr. P if he is allergic reaction or sign
that inhibits cell- drug or other to penicillin or and symptoms of
wall synthesis cephalosporins. cephalosporin. superinfection
promoting osmotic  Use cautiously in  Obtain specimen promptly.
instability. Usual patients for C/S, test before  Advise him to
bactericidal. hypersensitive to giving first dose. modify prescriber
penicillin because of Therapy may begin once with loose
Indications: possibility of cross while awaiting stool or diarrhea.
sensitivity with other results.
 Respiratory beta-lactams
Tract Infection
74
Drug Study
Generic Name: Norvasc Brand Name : Amlodipine
Classification: Anti-angina Date Started : June 23, 2009
Teaching
 Inhibits -10 mg 1 tab q  Contraindicated in  ALERT: Monitor Mr.  Caution Mr.
calcium ion nflux 12° patient hypersensitive P carefully. Some P to continue
across cardiac and to drug. patients especially those drug even when
smooth-muscle  Use cautiously in with severe obstructive feeling better.
cells, thus patients receiving other coronary artery disease,  Tell him
decreasing peripheral vasodilators, have developed increased that S.L.
myocardial especially those with frequency, duration, or nitroglycerin
contractility and severe aortic stenosis, severity of angina or may be taken as
oxygen demand; and in those with heart acute MI after initiation needed when
also dilate failure. Because drug of calcium channel angina
coronary arteries, is metabolized by the blocker therapy or at symptoms are
and arterioles. liver, use cautiously time dosage increase. acute.
and in reduced dosage  Monitor blood
in patients with severe pressure frequently
hepatic disease. during initiation of
therapy because drug-
induced vasodilation has
a gradual onset, acute
hypotension is rare.
75
Drug Study
Generic Name: Telmisartan Brand Name : Micardis
Classification: Angiotensin II Antagonists Date Started : June 23, 2009
Teaching
 Treatment for -80 mg 1 tab OD  Allergy to  Monitor client for  Tell Mr. P
essential Telmisartan or to hypotension after starting that if he feels
hypertension ACE inhibitors. drug. Place client supine dizzy or has
 Blocks  Contraindicated if hypotension occurs, low blood
vasoconstricting in patient that has and give IV normal pressure on
and aldosterone inability to urinate. saline, if needed. standing he
secreting effects of  For patients whose should lie
angiotensin II by renal function may down, rise
selectively blocking depend on the activity of slowly from
the binding the rennin angiotensin- lying to
angiotensin II to the aldosterone system (such standing
angiotensin I as those with severe position, and
receptor in many heart failure) treatment climb stairs
tissues, such as with ACE inhibitors and slowly.
vascular smooth angiotensin receptors  Tell him that
muscle and the antagonist has caused drug may be
adrenal gland. oliguria or progressive taken without
azotemia and acute renal regard to
failure or death. meals.
76
Drug Study
Generic Name: Norvasc Brand Name : Amlodipine
Classification:Anti-angina Date Started : June 23, 2009
Teaching
 Inhibits calcium -10 mg 1 tab q 12  Contraindicated  Caution Mr. P
from influx across hours to patient  Monitor BP to continue taking
cardiac and smooth hypersensitive to frequently during drug even when
muscle cells; thus drug. initiation of therapy. feeling better.
decreasing  Use cautiously in  Notify doctor if  Tell him S.L.
myocardial patient receiving signs of heart failure nitroglycerine
contractility and other peripheral occur, swelling of may be taken as
oxygen demand; vasodilators . hands and feet, needed when
also dilates shortness of breath angina symptoms
coronary arteries are acute.
and arterioles.
77
Drug Study
Generic Name: Cilastatin Sodium Brand Name : Meronem
Classification: Antibiotic Date Started : June 24, 2009
Mechanism Of Action Dose/Route Contraindications Nursing Responsibilities Patient/Family
Teaching
 Inhibits cell 1 g/IV q 12 hours  Patients with  Reconstitute for IV use by  Advise
wall synthesis systemic allergic mixing with 100 ml of diluents Mr. P to
 Bactericidal reaction to pork when  Base initial dose on the report any
against a wide porcine derived type and severity of infection. unusual or
range of gram products are used or Give doses between 200 and persistent
negative organisms. hypersensitivity to any 500 mg by IV infusion over 20- adverse
 Stable in the components of 30 minutes. Give doses of 1 g effect or
presence of bêta- preparation by IV infusion over 40-60 lack of
lactamases.  Episodes of minutes. If Nausea develops, response.
hypoglycemia decrease infusion rate
Indications:  Reconstituted IV solutions
vary from colorless to yellow
 lower while reconstituted IM solutions
respiratory tract vary from white to light tan in
infection, color. Color variations do not
affect potency.
 Do not mix with other
antibiotics; however, may be
administered with other
antibiotics, if necessary
78
79
Generic Name: Esomeprazole Brand Name : Nexuim
Classification: Antiulcer agents, Proton-pump inhibitor Date Started June 24, 2009
 Binds to an -40 mg/tab, 1 tab OD  Assess Mr. P  Assess Mr. P  Instruct Mr. P
enzyme on gastric routinely for routinely for epigastric to take
parietal cells in the epigastric or or abdominal pain and medication as
presence of acidic abdominal pain and frank or occult blood in directed for the
gastric pH, frank or occult blood stool, emesis or gastric full course
preventing the in stool, emesis or aspirate therapy, even if
final transport of gastric aspirate  Constant feeling better
hydrogen ion into  Constant assessment for adverse  Take missed
the gastric lumen. assessment for reactions does as soon as
adverse reactions remembered but
not if almost
time for the next
dose. Do not
double doses
 Advise him to
avoid alcohol,
products
containing
aspirin or
NSAIDS, and
for food that
may cause
increase GI
irritation.
 Advise him to
report onset of
black tarry
stools; diarrhea;
abdominal pain;
or persistent
80
headache to
health care
professional
promptly
Drug Study
81
Generic Name: Montelukast Sodium Brand Name : Singulair
Classification:Bronchodilators/Anti-Asthma Date Started : June 25, 2009
Mechanism of Dose/Route Contraindications Nursing Responsibilities Patient/Family Health

Action Teaching
 Selective -1 tablet once a day  Use cautiously and  Assess Mr. P’s  Instruct Mr. P to
Competitive per orem with appropriate underlying condition, take the drugs at
Leukotriene monitoring in patient and monitor patient for bedtime.
receptor whose dosages of effectiveness.  Tell him to discard
antagonist systemic  Oral granules may be any unused portion.
that reduces corticosteroids may given without regard to  Advise him to take
early and late- be reduced gradually. meals. drug daily, even if
phase asymptomatic, and to
broncho- contact his prescriber
constriction if isn’t well
from antigen controlled.
challenge.
Indications:
 asthma,
seasonal
allergic
rhinitis
Drug Study
82
Generic Name: Ipratropium Bromide Brand Name: Combivent
Classification: Bronchodilator Date Started: June 27, 2009
Teaching
 Relaxes -1 Nebule every 15  Contraindicat  Monitor pulmonary  Rinse mouth
bronchial, vascular minutes x 3 doses ed in patint with function test before initiate with H2O after each
smooth muscle by hyperthropic therapy and periodically inhalation dose to
stimulating beta 2 obstructive during therapy to minimize dry mouth
receptors leading to cardiomyopathy determine the effect of the  Avoid smoking
bronchodilation. or drugs. and other respiratory
tachyarrythmia.  Observe for irritants.
Indications:  Hyprsensitivi paradoxical
ty to atropine or bronchoconstriction
 Management of its derivatives. ( allergic reaction, cough,
reversible sneezing), withhold the
bronchospasm drugs and report to the
associated with physician immediately.
obstructive airway  Nebulization should
disease in patient take place using a gas flow
who requires more 9o2 or compressed air) of
than a single 6-10 L/min and the
bronchodilator. solution nebulized over a
10-15 minute period.
Drug Study
83
Generic Name: Fluticasone Propionate Brand Name : Flixotide
Classification: Corticosteroid/Inhaled steroids Date Started : June 27, 2009
Mechanism of Dose/Route Contraindications Nursing Responsibilities Patient/FamilyTeachi

Action ng
 Anti- -1 nebule single Contraindicated as  Because of risk of systemic  Tell Mr. P that
inflammatory and dose only. primary treatment absorption of inhaled drug isn’t indicated
vasoconstrictor of patient with corticosteroids, observe patient for the relief of
that may decrease status asthmaticus carefully for evidence of acute
inflammation by or other acute systemic corticosteroids effects. bronchospasm.
inhibiting mast episodes of asthma  Monitor Mr. P especially post-  Advice him to
cells requiring more operatively or during periods of use drug at regular
macrophages, and intensive stress, for evidence of intervals, as
mediators such as measures. inadequate adrenal response. directed.
leukotrienes. Use cautiously in  If bronchospasm occurs after a
breast-feeding dose of flurticasone inhaled,
 Indications: patients. aerosol treat immediately with a
fast-acting inhaled
 As bronchodilators.
preventive in
maintenance of
chronic asthma in
patients requiring
oral
corticosteroids.
Drug Study
84
Generic Name: Ventolin Brand Name Available : Salbutamol
85
Classification: Bronchodilator Date Started : June 27, 2009

Teaching
 Binds to beta₂- 1 nebule every 4  Hypersensitivity to  Assess lung Instruct Mr. P to:
adrenergic hours via inhalation adrenergic amines sounds, pulse and
receptors in  Hypersensitivity to blood pressure before  Take albuterol
airways smooth fluorocarbons (some administration and as directed. If on
muscle, leading to inhalers) during peak of a scheduled
activation of medication. Note dosing regimen,
adenyl cyclase and Use Cautiously in: amount, color, and take missed dose
increased levels of character of sputum as soon as
cyclic-3’,5’-  Cardiac disease, produced remembered,
adenosine hypertension, diabetes,  Monitor spacing remaining
monophospate  Excess inhalers pulmonary function doses at regular
(cAMP). used may lead to tests before initiating intervals.
Increase in cAMP tolerance and therapy; and  Do not use
activate kinases, paradoxical periodically during albuterol first if
which inhibit the bronchospasm therapy to determine using other
phosphorylation of effectiveness of inhalation
myosin and Adverse Reactions: medication medications and
decrease  Observe for allow 5 minutes
intracellular Nervousness, restlessness, paradoxical to elapse before
calcium relaxes tremors, headache, bronchospasm administering
smooth muscle insomnia, chest pain, (wheezing). If other inhalant
airways palpitations, angina condition occurs, medications
 Relaxation of arrhythmia, hypertension, withhold medication unless otherwise
airways smooth nausea and vomiting, and notify physician directed double
muscle with hyperglycemia, or other health care doses or increase
subsequent hypokalemia, professional the dose or
bronchodilation hyperactivity in children. immediately frequency of
 Relatively  Inhalation: Shake doses.
86
selective for beta₂ well and allow at least  Notify health
(pulmonary) 1 minute between care professional
receptors inhalations of aerosol if no respose to
medication. Prime the the usual dose of
Indications: inhaler before first use albuterol or if
by releasing 4 test contents of one
 Used as a spray from the face. canister are used
bronchodilator to  For nebulizer, in less than 2
control and prevent compressed air or week.
reversible airway oxygen flow should  Not to exceed
obstruction caused be 6-10 L/min, a recommended
by asthma or single treatment of 3 dose; may cause
COPD ml lasts about 10 min. adverse effects;
 Inhalation: paradoxical
Used as quick- bronchospasm
relief agent for (more likely with
acute first dose from
bronchospasm and new canister), or
for prevention of loss of
exercise induced effectiveness of
bronchospasm medication
 Contact health
care professional
immediately if
shortness of
breath is not
relieved by
medication or is
accompanied by
diaphoresis,
dizziness,
palpitations, or
87
chest pain
 Proper use of
metered dose
inhaler, rotahaler
or nebulizer
 Prime unit
with 4 sprays
before using and
to discard canister
after 200 sprays.
Actuators should
not be changed
among products
 Rinse mouth
with water after
each inhalation
dose to minimize
dry mouth
 Albuterol may
cause an unusual
or bad taste
Drug Study
88
Generic Name: Furosemide Brand Name : Lasix
Classification: Diuretics Date Started : June 29, 2009

Teaching
 Inhibits the re- - 20mg/ amp IV  Hypersensitivity  Assess fluid status  Inform
absorption of - 40mg/ tablet with  Cross sensitivity during therapy. Monitor Mr. P of
sodium and chloride tablet per orem once with Thiazides and daily weight, I & O ratios, possible
from the loop of a day Sulfonamide may amount and location of need for
Henle and distal occur edema, lung sounds, skin high
renal tubule  Pre- existing turgor, and mucous potassium
 Increase renal electrolyte imbalance, membranes. Notify the or
excretion of water, hepatic coma or physician if thirst, dry magnesium
sodium, chloride, anemia mouth, lethargy, weakness, supplement
magnesium hypotension oroliguria s.
hydrogen and Special Consideration occurs.  Advise
calcium - Electrolyte depletion  Monitor BP and pulse him to
before and during immediatel
Indications: administration. y report
 Assess Mr. P who is ringing in
 Acute also receiving Digoxin for ears, severe
pulmonary edema anorexia, nausea and abdominal
 Maybe adjunct vomiting, muscle cramps, pain or sore
to other paresthesia and confusion. throat and
antihypertensive if  Assess Mr. P for tinnitus fever, this
needed. and hearing loss. symptoms
may
indicate
furosemide
toxicity.
 Caution
him to
change
positions
slowly to
89
minimize
orthostatic
hypotension
.
Drug Study
Generic Name: Human Isophane Insulin Brand Name : Insulatard
Classification: Intermediate acting insulin Date Started : June 30, 2009
Teaching
 Increase -20 units SQ in the  Contraindicated  Use only the  Make sure
glucose transport morning drug episodes of syringes calibrated for Mr. P knows
across muscle and hyperglycemia. the particular that drug
fat cell membranes  Contraindicated concentration of insulin relieves
to reduce glucose in patients with given. symptoms but
90
level. Help convert history of systemic  To mix insulin doesn’t cure
glucose to allergic reaction to suspension, swirl vial disease.
glycogen; triggers pork when gently or rotate  Instruct him
amino acid uptake porcine-derived between palm and about nature of
and conversion to products are used thigh. Don’t shake disease and
protein in muscle or hypersensitivity vigorously, this cause importance of
cell; stimulates to any component bubbling and air in following
triglycerides of preparation. syringe. therapeutic
formation and  Monitor blood regimen,
inhibits release of sugar adhering to
free fatty acid Prior to giving of specific diet,
from adipose insulin. losing weight,
tissue; and  Store insulin in getting
stimulates cool area. Refrigeration exercise,
lipoprotein lipase is desirable but not following
activity, which essential. personal
converts  Check expiration hygiene
circulating date on vial before program and
lipoproteins to using content. avoiding
fatty acid.  Press but don’t rub infection.
site after injection. Emphasize
Indications: Rotate injection sites to importance of
avoid overuse of one timing
 Regular area. injections with
Insulin. eating and of
not skipping
meals.
 Teach him to
avoid alcohol se
because it lower
glucose level.
 Instruct him
91
on proper use of
equipment for
monitoring
glucose level.
 Advise
patient to avoid
vigorous
exercise
immediately
after insulin
injection.
Drug Study
92
Generic Name: Theophylline Brand Name : Nuellin
Classification: Bronchodilator Date Started : July 1. 2009

Teaching
 Inhibits  Contradicated in patient  Give drug around the  Inform Mr.
phospodiesterase: the -250 mg. 1 tablet, 1 hypersentivity to clock, using extended P that dizziness
enzyme that degrades tablet twice daily per xanthine compounds release product at bed is common at
CAMP, resulting in orem (caffeine, theobromine) time. start of therapy.
relaxation of smooth and in those with active  Monitor VS, Warn him to
muscle of the peptic ulcer or poorly measure and record fluid take drug
bronchial airways controlled seizure intake and output. regularly, only
and pulmonary blood disorder. Expect improved quality as directed.
vessels.  Use cautiously with or pulse and respiration.
COPD patients, cor
Indications: pulmonale, renal or
hepatic disease, peptic
 Acute attacks of ulceration, DM,
asthma and reversible glaucoma, severe
bronchospasm hypoxemia,
associated with hypertension,
bronchial asthma, compromised cardiac or
bronchitis, circulatory function,
emphysema and angina, acute MI or
related condition. sulfite sensitivity.
Drug Study
93
Generic Name: Acetylcysteine Brand Name : Fluimucil
Classification: Mucolytic Date Started : July 2, 2009
Mechanism of Dose/Route Contraindications Nursing Responsibilities Patient/Family Teaching

Action
 Mucoly -600 mg 1 tablet, 1  Contraindicated in  Drug smells strongly  Warn Mr. P that
tic that tablet in ½ glass of patient of sulfur. Mixing oral drug may have foul
reduces the H2O one a day per hypersensitivity to form with juice or cola taste or smell.
viscosity of orem. drug. improves its taste.  For maximum
pulmonary  Use cautiously in  Drug delivered effect, instruct him to
secretions elderly or debilitated through nasogastric tube clear his airway by
by splitting patients with severe maybe diluted with coughing before
disulfide respiratory water. aerosol administration,
linkages insufficiency. Use IV  Monitors cough type if indicated.
between formulation cautiously and frequency.
mucoprotein in patients with asthma  Use fresh dilutions
molecular or history of mix in 1 hour. Store
complexes. bronchospasm. undiluted solutions that
Also restore have been opened in the
liver stores refrigeration for up to 96
of hours.
glutathione
to treat
acetaminop
hen toxicity.
Indications:
 Adjunc
t therapy for
abnormal
viscid or
thickened
mucous
secretion in
patient with
94
pneumonia,
and
emphysema.
Drug Study
Generic Name: Clopidogrel Brand Name : Plavix
Classification: Anticoagulants Date Started : July 4, 2009
Mechanism of Action Dose/Route Contraindications Nursing Responsibilities Teaching
 Inhibits the -75 mg 1 tab once a  Contraindicated  Platelet  Advise Mr. P
binding adenosine day in patient aggregation won’t that it may take
diphosphate (ADP hypersensitive to return to normal for longer than usual to
for its platelet drug or its at least 5 days after stop bleeding. Tell
receptor, impeding components and in drug has been him to refrain from
ADP-mediated those with stopped. activities in which
activated and pathologic bleeding  Don’t confuse trauma and
subsequent platelet (such as peptic ulcer Plavix with Paxil. bleeding may
95
Generic Name: Methylprednisolone Brand Name : Medrol
aggregation.
Classification: Corticosteroids or intracranial Date Started : occur, and
July 4, 2009
Clopidogrel hemorrhage). encourage him to
irreversibly  Use cautiously in wear a seatbelt
Teaching
modifies the patient at risk for when in a car.
Not clearly
platelet -16 mg 1 tab OD  Contraindicated in  Determine whether  Instruct Mr. P
ADP increased bleeding  Instruct him to
defined. Decrease patient hypersensitive Mr. P is sensitive to and family to
receptor. from trauma, notify prescriber if
inflammation, to drug or its other corticosteroids. watch for signs of
Indications: surgery or other unusual bleeding or
mainly by ingredients, in those  Most adverse bleeding or
 To reduce pathologic bruising occurs.
stabilizing with systemic fungal reactions to bruising and to
thrombotic event in conditions and those notify doctor
leukocyte infection, in corticosteroids are dose-
patients with with hepatic immediately if any
lysosomal premature infants, and duration-dependent.
atherosclerosis impairment. occur.
membranes, in patients receiving  For better results and
documented by  Tell him to
suppress immune immunosuppressive less toxicity, give a once-
recent CVA, MI or avoid OTC drugs
response, stimulates doses together with daily dose in the
peripheral arterial containing
bone marrow; and live virus vaccine. morning.
disease. Aspirin, other
influences protein,  Used cautiously in  Give oral dose with
fat and patients with GI food when possible. May salicylates, or
carbohydrates ulceration or renal need to take drug drugs that may
metabolism. isolase, hypertension, together with antacids or interact with
osteoporosis, H2O receptor Heparin unless
Indications: cirrhosis, seizure, antagonists. ordered by doctor.
 Severe active hepatitis,  Always adjust to
inflammation or lactation lowest effective dose.
immunosupression  Monitor Mr. P s
weight, BP, electrolyte
level and sleep pattern.
Euphoria may initially
interfere with sleep.
96
Drug Study
97
Drug Study
Generic Name: Floxel Brand Name : Levox
Classification: Antibiotic/Quinolones Date Started : July 7, 2009
Teaching
 Senusynthetic 500 milligrams 1  Hypersensitivity  Obtain C/S before  Instruct Mr. P to
anti-bacterial agent tab once a day to Leucofloxacin or starting drug therapy rinse mouth
that inhibits any other quinolones. to identify if correct frequently and use
bacterial DNA Indications:  Epilepsy, history treatment has been sugarless candy as
gyrase necessary of tendon disorders. initiated. gum for dry mouth.
for supercoiling Treatment of adult  Assess renal  Instruct him since
(conversion of in mild to function: urine output, he is diabetic to
intermediate moderate severe monitor BUN monitor glucose
fragments into high infection cause by creatinine, serum level regularly. A
molecular weight susceptible strains electrolytes,K, Na and hypoglycemic
DNA), thereby microorganism Cl. reaction may occur.
preventing DNA  Assess liver
replication, function; jaundice
transcription repair clay colored stool if
and recombination patient is long-term
in susceptible therapy.
bacteria.
98
Nursing Care Plan
Date: June 30, 2008
CUES NURSING GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS AND OBJECTIVE INTERVENTION
ANALYSIS
Subjective Data: Impaired Gas Within 8 hours of Instructed and These techniques Goal was met.
Exchange related to nursing encouraged Mr. P to improve ventilation Within 8 hours of
"Medyo nahihirapan inability to intervention, the do diaphragmatic by opening airways nursing
akong huminga", as adequately expel patient's breathing and to facilitate clearing intervention, Mr. P's
verbalized by Mr. P Carbon Dioxide oxygenation will be effective coughing. the airways of oxygenation
(CO2) efficiently in normal limits as sputum. Gas improves.
Objective Data: evidence by normal exchange is
Ph 7. 32 Analysis: oxygen saturation, improved and
PCO2 51 less dyspnea. fatigue is
PO2 80 By the process of minimized.
HCO3 30 diffusion the
O2 Saturation of exchange of oxygen Maintained in semi- 30-45 degree angle
92% and carbon dioxide fowlers position helps and promote
- Partial occurs in the lung expansion thus
99
Compensated alveolar-capillary increasing
Respiratory membrane area. The oxygenation.
Acidosis with mild relationship
hypoxemia
Nursing Care Plan

ANALYSIS
Continuation. Between ventilation Administer oxygen Oxygen will correct

(airflow) and by method hypoxemia.
RR – 24 cycles per perfusion (blood prescribed.
minute; flow) and perfusion
Use of Accessory (blood flow) affects Administered
Muscle; the deficiency of the bronchodilators as Bronchodilators
Pursed lip gas exchange. prescribed dilate the airways.
Breathing; Normally there is a The medication
Expectoration of balance between dosage is carefully
thick moderate ventilation and adjusted for each
yellowish secretion perfusion; however, patient, in
ceratin conditions accordance with
can offset this clinical response.
balance resulting in
impaired gas Administered Combining
exchange. nebulizer medication with
100
aerolized
bronchodilator is
Nursing Care Plan

ANALYSIS
Continuation. typically use to

control
bronchoconstriction
in an acute
exacerbation.
101
Nursing Care Plan
Date: June 30, 2009

ANALYSIS
Subjective Data: Ineffective airway Patient will Assessed respiratory Provides basis for Goal partially met.
clearance related to demonstrate rate. evaluating adequacy
"Medyo mahirap increased improvement in of ventilation. Following an 8-hour
huminga dahil sa production of oxygenation and nursing
plema", as bronchial ventilation by Auscultated breath Crackles indicate intervention, the
verbalized by Mr. P secretions. expectorating sounds; noted areas accumulation of patient's respiratory
secretions; patient with presence of secretions and rate is 26 cycles per
Objective Data: Analysis: will manifest clear adventitious breath inability to clear minute.
Ph 7. 32 The exposure or breath sounds, sounds. airways.
PCO2 51 presence of noxious relieved dyspnea Display decreasing
PO2 80 irritants such as and normal Performed chest- CPT helps amount of
HCO3 30 smoke particles and respiratory rate. physiotherapy secretions to be secretions (less than
O2 Saturation of dust to the expelled from the 4000 ml)
92% bronchial tree lungs and used to
- Partial stimulates the assist a cough and Presence of cackles
Compensated goblet cells to to try to improve
Respiratory secrete mucus.
102
Nursing Care Plan
ANALYSIS
Acidosis with mild In COPD, there is Ventilation by

hypoxemia hypersecretion of physical means.
mucus as a result of
Abnormal breath prolonged exposure Documented. Expectorations may
sounds: crackles on to noxious particles. respiratory be different when
right and left lung Thus, the secretions secretions: character secretions are very
bases. thicken the airway and amount of thick.
and limit the airflow sputum
Dyspnea: use of movement.
accessory muscles Maintained patient To maximize lung
for respiration; in semi-fowlers. expansion.
elevated shoulder
Administered Muculytic agent
Increase in muculytic as help improve
respiratory rate : 26 prescribed oxygenation by
cycles per minute clearing the airways
with thick tenacious
secretions.
103
Nursing Care Plan
ANALYSIS
Continuation Exhalation to slow

the breathing rate,
causing general
relaxation.
104
Nursing Care Plan
Date: July 01, 2007

ANALYSIS
Risk for impaired Goal:
Subjective Data: skin integrity Independent: Client was able to
related to prolonged To maintain skin maintain skin
“Lagi nalang ako bed rest integrity as Placed client in a To prevent muscle integrity as
nakahiga”, as evidenced by no comfortable aches and evidenced by no
verbalized by the Analysis : redness over bony position backaches redness over bony
client. prominences and prominences and
Immobility, which absence of skin Assessed general To determine skin
Objective Data: leads to pressure, skin condition turgor and the skin absence of skin
breakdown breakdown
shear, and friction, specifically skin over bony
Awake is the factor most Objectives: over bony prominences are
Limited range of likely to put an prominences stretched tautly
individual at risk for Long Term:After 1 result of
motion week of nursing
altered skin compression of skin
Body weakness integrity. Advanced intervention, client capillaries between
age; the normal loss will be able to a hard surface and
Present weight 160 maintain clean
of elasticity; the bone
kg as of July 1, moist skin and
inadequate
2009 verbalizes increase
nutrition;
comfort
105
Nursing Care Plan
ANALYSIS
Continuation environmental Short Term: Assessed client’s Immobility causes

moisture, especially ability to move skin breakdown
from incontinence; After 30 minutes of Encourage frequent
and vascular effective health position changes in Reduces pressure on
insufficiency teaching the client bed, assist with tissue, improving
potentiate the will be able to active/passive range circulation and
effects of pressure verbalized of motion reducing time any
and hasten the understanding of one area is deprived
development of skin skin care. of full blood flow
breakdown. Groups
of persons with the Provided adequate To prevent pressure
highest risk for clothing/covers; to certain parts of
altered skin protect from drafts the body
integrity are the
spinal cord injured Emphasized To maintain general
and those who are importance of good health and
confined to bed or adequate nutritional/ good skin turgor
wheelchair for fluid intake
prolonged periods
of time.
106
Nursing Care Plan
ANALYSIS
Advised the family Promotes

Continuation. member to elevate involvement of
lower extremity of family member in
the client from time healthcare regimen
to time and promotes
venous return
Instructed family to To prevent risk of
keep the nails of the skin damage
client short
regularly
Excessive dryness
Demonstrated to or moisture
family members damages skin and
frequent skin care; hastens breakdown
minimize contact
with
moisture/excretions
107
Nursing Care Plan
Date: July 06, 2007

ANALYSIS
Subjective Data: Goal: Independent: Minimizes Client was able to

Activity intolerance exhaustion and walk around the
“Medyo madali ako related to imbalance To promote optimal Assisted with self- helps balance room with
mapagod” as between oxygen physical condition care activities as oxygen supply and assistance,
verbalized by the supply and demand and to maintain necessary demand that allows intolerance to
client. as manifested by satisfactory lifestyle conservation of activity noted; client
fatigue and performing physical energy exhibited dyspnea
Objective Data: exertional dyspnea activities with respiratory rate
Conscious and upon ambulation. independently. of 29 breaths per
ambulatory; Tires Assisted client to
Analysis: Objectives: minute.
easily and needs plan activities with This will help
assistance doing Most activity Long Term: rest periods between reduce feeling of
activities of daily intolerance is activities easy fatigability
living; With mild related to generalize After 2 weeks of
difficulty in weakness, intervention client
breathing doing imbalance between will be able to
mobility activities; oxygen and tolerate activities
108
Nursing Care Plan
ANALYSIS
Continuation supply demand as with absence of Taught client to This prevents

well as acute or dyspnea and gradually increase overexerting the
With oxygen at chronic diseases. excessive fatigue activity as client heart and promotes
4liters per nasal This is apparently and exhibit tolerates such as attainment of short-
cannula seen to elderly acceptable normal active range of range goals.
clients with diseases range of vital signs. motion exercises in
of respiratory, bed, progressing to
Vital Signs: with cardiovascular sitting and standing
HR of 92 beats per problems as well as Short Term:
to those with Monitored patient’s Facilitates choice of
minute; with BP of After 8 hours of response to activity intervention and
140/90mmhg; with diabetes.
intervention client and note for any establishes client’s
RR of 25 breaths will be able to walk changes of vital capabilities
10 steps without the signs, note reports
presence of any of dyspnea, fatigue
signs of distress. during and after
activities
109
Nursing Care Plan
ANALYSIS
continuation Provided quiet Enhances rest to

environment and lower body’s
instruct client to oxygen
have bed rest requirements and
reduces strain on the
heart and lungs
Elevated the head of Enhances lung

the bed as tolerated expansion to
maximize
oxygenation for
cellular uptake
Educated client Nourishes every cell

proper deep of our body and
breathing exercises promotes relaxation
three times daily
110
Nursing Care Plan
ANALYSIS
continuation Prolonged
exhalation helps get
rid of stale air and
toxins in our lungs
Assisted patient to Enhances self-

maintain positive esteem and patient
attitude and provide develop a positive
emotional support outlook doing his
while increasing activities of daily
activity living
Dependent:
Identifies
Monitored deficiences in RBC
laboratory studies. components
Hb, Hct and RBC affecting oxgen
count and Arterial transport and
blood gases treatment needs or
response therapy
111
Nursing Care Plan
ANALYSIS
continuation Instructed the Promotes

family to help and partnership with the
assist the client with family to take care
activities of daily of the client
living
Instructed the
family to be with Recognizes the
the client upon family involvement
ambulation and and allows the client
doing mobility to know that family
activities members are
welcome
Educated the family Promotes

to note any changes information and
upon ambulation, recognizes the need
necessity to stop the of the family
activity and the member
client’s need to rest.
112
Discharge Planning
Our patient, Mr. P, was discharged on July 08, 2009. The following home instructions
were given to prevent him from future attacks of exacerbations.
MEDICATIONS
MEDICATIONS DOSAGE/ROUTE TIMING ACTIONS PRECAUTIONS/

CONSIDERATIONS
Montelukast 1 tablet OD HS Bronchodilators should not be used for

/Antiasthma acute asthma attack
Nuellin 250 mg 1 tab BID 9AM/6PM Bronchodilators Dizziness is common at

start of therapy. Warn
patient to take drug
regularly, only as
directed.
Fluimucil 600 mg 1 tab OD 9AM Mucolytic Warn patient that drug

may have foul taste or
smell that some patient
find distressing.
Norvasc 10 mg 1 tab BID 9AM/6PM Anti-angina Caution patient to

continue taking drug
even when feeling
better. Tell patient S.L.
nitroglycerine may be
taken as needed when
angina symptoms are
acute.
Discharge Planning
113
CONSIDERATIONS
Micardis 80 mg 1 tab OD 9AM/6PM Antihypertensive Tell patient that if he

feels dizzy or has low
blood pressure on
standing he should lie
down, rise slowly from
lying to standing
position, and climb
stairs slowly
Plavix 75 mg 1 tab OD 9AM/6PM Anticoagulant Advise patient that it

may take longer than
usual to stop bleeding.
Tell him to refrain from
activities in which
trauma and bleeding
may occur. Instruct
patient to notify
prescriber if bruising
occurs.
Lasix 40 mg 1 tab OD 9AM/6PM Diuretic Inform patient of

possible need for high
potassium or
magnesium
supplements.
Advise patient to
immediately report
ringing in ears, severe
abdominal pain or sore
throat and fever, this
symptoms may indicate
furosemide toxicity.
Discharge Planning
114
CONSIDERATIONS
Bactrim Forte 1 tablet BID 9AM/6PM Sulfonamide Tell patient to take drug
Combination as prescribed, even if
/Bactericidal he feels better.
Encourage patient to
drink plenty of fluids.
Advise patient to avoid
prolonged sun
exposure, wear
protective clothing and
use sun screen.
Solosa 1 mg 1 tab OD 9AM/6PM Antidiabetic Regular monitor of

agent glucose level in the
blood and urine
There is no specific cure for COPD however there are safe and effectve medicines
that can help control the symptoms. A doctor’s prescription is needed to get these
medications. Since COPD symptoms are variable-they can change or get worse. It is
important that the patient know when to call the doctor to adjust medicine depending on
how the patient feels.
Bronchodilators
Bronchodilators help reduce your breathing effort. They open up the airways in your
lungs to relieve or reduce shortness of breath and wheezing.
Mucolytics
Mucolytic reduces the viscosity of pulmonary secretions by splitting disulfide

linkages between mucoproteins molecular complexes. Also, restore liver stores of glutathione
to treat acetaminophen toxicity.
115
Discharge Planning
Antidiabetics
Lowers glucose level.
Antianginals
Inhibits sodium ion influx across cardiac and small muscle cells, thus decreasing
myocardial contractility and oxygen demand, also dilates coronary arteries and arterioles.
Antihypertensive
Lowers blood pressure.
Anticoagulants
To reduce thrombotic events in patients with atherosclerosis.
Diuretics
Loop diuretic that inhibits sodium and chloride re-absorption.
Antibiotics for COPD

Mr. P's lung’s natural defense systems are not as effective as they normally would be.
He is very susceptible to have a higher risk of lung infections.
He will need antibiotics to protect his lung: even mild infection can turn out to be
very serious when your lungs cannot protect themselves.
EXERCISES
How to control Mr. P's breathing
If he knows how to control his breathing, he can stay calm when he is short of breath.
Pursed-lip breathing and diaphragmatic breathing will both help. These breathing methods
prevent or reduce the trapped air in his lungs, and allow him to breathe in more fresh air.
Discharge Planning
116
Pursed lip breathing as instructed to Mr. P
• Breathe in slow through your nose for 1 count
• Purse your lips as if you were going to whistle
• Breathe out gently through pursed lips for 2 slow counts (breath out twice as slowly
as you breathed in). Let the air escape naturally-don’t force the air out of your lungs
• Keep doing pursed lip breathing until you’re no longer short of breath
Diaphragmatic breathing as instructed to Mr. P

• Put one hand on your upper chest, and the other on your belly just above your waist.
• Breath in slowly through your nose-you should be able to feel the hand on your belly
moving out. The hand on your chest shouldn’t move
• Breath out slowly through your pursed lips-you should be able to feel the hand on
your belly moving in as you exhale (breath out).
How to cough up phlegm: controlled coughing

People with COPD usually have extra phlegm (mucus) in their lungs, as what Mr. P
manifests. If a person has phlegm, he should cough it up. If the phlegm stays in his lungs, it
can clog his smaller airways, making it hard to breathe. The phlegm could also become
infected.
Controlled coughing helps M. P to clear the phlegm from his lungs.
Instructions to Mr. P
1. Sit down and make yourself comfortable.
2. Lean your head forward slightly.
3. Place both feet firmly on the ground.
4. Breath in deeply using diaphragmatic breathing (push your belly out while you breath in).
5. Try to hold your breath for three seconds.
6. While keeping your mouth slightly open, cough out twice. You should feel your
diaphragm pushed upward while you do this. The first cough should bring up the phlegm,
and the second cough should move it towards the throat.
Discharge Planning
117
7. Spit the phlegm out into a tissue. Remember to check the color, if the phlegm is yellow,
green or brown, or has blood in it, call your doctor.
8. Throw out the tissue right away.
9. Take a break and repeat these steps once or twice if necessary.
Exercising is a way of taking control of your COPD. Exercise can:
 Improve oxygen utilization

 Reduce shortness of breath
 Increase your work capacity
 Build muscle strength to help you stay active
Lack of exercise affects people with COPD in some of the same ways it affects people
without COPD:
Muscles, including your heart, will get weaker

Shortness of breath may increase
The capacity to exercise will decrease
The immune system may weaken, making it harder for you to fight infection
There are psychological benefits, too:
Exercise almost always helps you feel good about yourself

You may find yourself less anxious about shortness of breath
You might just feel less tired and more energetic
Increased energy will help you be more independent
Taking control of your COPD through exercise is about improving the quality of your life.
TREATMENT
Home Oxygen Therapy:

Hook to O2 @ 2lpm via nasal cannula during the day.
Discharge Planning
118
Supplement is a medicine that a doctor may prescribe. Not everyone with COPD
needs oxygen. Many people believe that being “put on oxygen” is a sign that they’re
desperately sick.
This is not always true. For some people, oxygen is an important part of regular
therapy. For others, it may be a short-term treatment.
Generally, oxygen therapy can benefit people with:
 Very low blood-oxygen levels

 Temporary lung damage from infection (like pneumonia)
 Only people who suffer from significant low-oxygen levels will benefit from oxygen.
Ask your doctor to test to see of oxygen might help you.
Nebulization
A nebulizer is an air compressor, often called a breathing machine, used to inhale
liquid medicine.
The following are the steps on how to use the nebulizer:
 Assemble the nebulizer according to its instruction. Connect the hose to an air
compressor.
 Fill the medicine cup with your prescription, according to the instruction,
 Attach the hose and mouthpiece to the medicine cup.
o Place the mouthpiece in your mouth. Breathe through your mouth until all the
medicine is used, about 10-15 minutes. Some people use a nose clip to help
them breath only through the mouth.
 Wash the medicine cup and mouthpiece with water, and air-dry until your next
treatment.
HYGIENE
 Wash hands frequently.

 Do mouth care.
 Wear clear and comfortable clothing and footwear.
Discharge Planning
119
 Use handkerchief or tissue when coughing and sneezing.
 Spit only on covered garbage can.
OUT PATIENT FOLLOW UP
 Make a follow-up appointment as three times a week in pulmonary rehabilitation.

 Mr. P was advised to call his doctor immediately when he experience:
1. Shortness of breath, wheezing, or coughing
2. Increase mucus
3. Yellow, green, bloody, or smelly mucus
4. Fever or chills
5. Tightness in your chest that does not go away with rest or medication
6. An irregular heartbeat
7. The primary goal of pulmonary rehabilitation is to restore the patient to
the highest possible level of independent functioning.
DIET
Maintain a Healthy Body Weight
Since Mr. P is overweight, his heart and lungs have to work harder to breathe.
Monitor Mr. P’s Body Weight
Weighing himself at least once a week will help him keep his weight under control. If he
has a weight gain or loss of 2 pounds in one day or 5 pounds in one week, he should contact
his doctor.
120
Discharge Planning
Drink Plenty of Fluids
Mr. P wa encouraged to drink 6 to 8, eight-ounce glasses of non-caffeinated beverages

daily. This helps to keep his mucus thin, making it easier for his body to cough it up. Some
people find it easier to fill a container full of their daily fluid requirement in the morning and
spread it out during the day. If he tries this method, it is best to slow down his intake of fluids
towards evening so he is not up all night urinating.
Decrease Sodium Intake
Eating too much salt causes Mr. P’s body to retain fluid. Too much fluid can make his
breathing more difficult. To reduce sodium intake, do not add salt in foods and make sure
that the one who buys foods in their family should read all food labels. If the sodium content
in food is greater than 300 milligrams of sodium per serving, it should be avoided.
Wear Your Oxygen Cannula While Eating
Since Mr. P has a prescribed continuous oxygen therapy, make sure he wears the
cannula when he eats. Since his body requires extra energy to eat and digest food, he will
need additional oxygen.
Avoid Overeating and Foods that Cause Gas
When someone overeats, his stomach can feel bloated making breathing more
difficult. Carbonated beverages or gas-producing foods such as beans, cauliflower or cabbage
can also cause bloating. Eliminating these types of beverages and foods will ultimately allow
for easier breathing.
Eat Smaller, More Frequent Meals
Mr. P was advised to eat six small meals a day instead three large ones. This will
prevent his stomach from distending and crowding the diaphragm which can cause shortness
of breath. He was also advised not to lie down after meals. Eat foods that are soft in
consistency to permit adequate nutrition without overtaxing the digestive system. Adjustment
in the diet’s carbohydrate and fat content may be beneficial to Mr. P (carbohydrate associated
hypercapnia).
121
Discharge Planning
Include Enough Fiber in Your Diet
High fiber foods such as vegetables, dried legumes, bran, whole grains, rice, cereals,
pasta and fresh fruit aid in digestion by helping the food move more easily through his
digestive tract. His daily fiber requirement should be between 20 to 35 grams of fiber each
day.
SPIRITUALITY /SEXUALITY
Three ways the nurse can help the patient to nurture his own spiritually are by:
1. Promoting meaning and purpose

a. Arrange for referral to a spiritual adviser
b. Explore with the patient spiritual practices from which strength and hope
might be derived
c. Referring the patient to appropriate support groups is also helpful
2. Promoting love and relatedness
a. Encourage and facilitate visits from the patient’s family, friends and spiritual
adviser.
3. Promoting forgiveness
a. Explore with the patient and family the importance of learning to accept
oneself and others, including both strengths and limitations
Enhancing Sexual Intimacy
To follow are some things to keep in mind about sex and COPD designed to enhance
sexual intimacy:
 First and foremost, Mr. P should talk to his wife honestly regarding his feelings about
having sex. This will keep the lines of communication open and allow his
partner to express their feelings in return.
 To avoid bronchospasm during intercourse, use a bronchodilator immediately prior to
and during sexual relations, if necessary.
 Avoid sexual activity immediately following a heavy meal. This may increase your
fatigability.
122
Discharge Planning
 Since Mr. P uses supplemental oxygen, plan on using the same amount during sexual
activity. Use extended tubing so there is enough to allow you to place the oxygen tank
away from the bed or completely out of the room if necessary.
 Make sure the room is at a comfortable temperature prior to engaging in sex. Use a
fan during intercourse to keep from overheating.
 Mr. P must clear his bronchial secretions prior to engaging in sexual activity. This
may lessen the severity of breathlessness during sex. If he is having difficulty clearing
his airway, try the controlled coughing technique.
 Choose sexual positions that require the least amount of energy. For example, laying
side to side during intercourse is much more comfortable and uses far less energy
than the top-bottom position.
 Plan to have his wife assume more of an active role during sex so that Mr. P will be
less fatigued.
 Because sexual activity takes energy, plan to engage in sex when Mr. P is feeling
most rested. If necessary, take short breaks during sex.
 Focus on hugging, kissing and touching, rather than on the sexual act itself.
123

Introduction

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Introduction

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Introduction

Chronic Obstructive Pulmonary Disease (COPD) – a group of diseases that cause

Goal and Objectives

Specifically, the group will be able to:

Address : Sta. Cruz, City of Manila

Birth Date : August 11, 1957

Age : 51 Years Old

Height : 5 feet and 9 inches/172 centimeters

Weight : 365 pounds/165 kilograms

Civil Status : Married

Birth Place : City of Manila

Religion : Roman Catholic

Date of Admission : June 18, 2009

Date of Discharge : July 08, 2009

Admitting Diagnosis : Chronic Obstructive Pulmonary Disease in Acute Exacerbation

Past Medical History

Personal, Environmental and Psychosocial History

CENTRAL NERVOUS SYSTEM

Upon inspection, abdomen was uniform in Rounded abdomen; liver or spleen

Anatomy and Physiology

Anatomy and Physiology

At the end of all the bronchioles are the

Anatomy and Physiology

Anatomy and Physiology

Diaphragm and Chest wall

The last part of the respiratory system

Chronic Bronchitis, a disease of the airways, is

In Emphysema, impaired gas exchanged (oxygen, carbon dioxide) results from

Altered function of alveolar macrophage

Destruction of alveolar walls and loss of elastic recoil of bronchial walls

Increased total Pulmonary hypertension

June 30, 2009 Progress weaning as Determine the client’s

6 LTP x 1.5 hrs Assess how well Mr. P is

Explain the weaning plan.

Cont. Progress weaning as signs and the amount of air

To help him relax and better

Using the T-piece technique,

Monitor for distress during

Cont. Progress weaning as Your client's oxygen

Also, he should remain

Watch for perspiration and

June 30, 2009 Start Bladder training Before beginning the

The catheter may be clamped

The nurse should expect, as

June 30, 2009 Extubation Obtain necessary oxygen

Explain procedure to client.

Apply appropriate personal

Oxygenate client with 100%

Cont. Extubation If possible, instruct the

Assess client's ability to

Cont. Extubation Document Toleration of

DATE KEY TASK / FOCUS OF

Course in the Ward

Cont. Start Non invasive Regular observation of the

Using a facial mask increases

Once a client's clinical

Course in the Ward

July 1, 2009 Mr. P for Chest x-ray Explain the procedure to

Explain the need to hold very

DATE KEY TASK / FOCUS OF

Course in the Ward

July 3, 2009 Mr. P for 2d-echo Facilitate diagnostic exam

Explain the procedure in